Axial spondyloarthritis (axSpA) is a chronic inflammatory condition that predominantly affects the spine and sacroiliac joints [1]. It can also involve peripheral joints and entheses, and extra-musculoskeletal manifestations (EMMs) such as acute anterior uveitis, psoriasis and IBD. Symptoms of axSpA typically begin in early adulthood but diagnosis can often take several years [2]. Chronic inflammatory pain and stiffness are well recognized as having adverse effects on quality of life, social participation and mental health [3–5].

Need for guideline update

Pharmacological management has advanced considerably since the previous BSR axSpA guideline [6] to incorporate new classes of biologic DMARDs (bDMARDs, including biosimilars), targeted synthetic DMARDs (tsDMARDs) and treatment strategies such as drug tapering. Therapeutic options for treating EMMs as index conditions have similarly evolved. The increasingly complex therapeutic landscape, with varying efficacy and safety of drugs for each disease manifestation, forms the context in which we aimed to update the BSR guideline for the treatment of axSpA with b/tsDMARDs. The key questions that the guideline sought to answer were published in the guideline scope [7], including the effectiveness and safety of targeted therapies; switching, combining, tapering or withdrawing targeted therapies; and treating to target. The guideline applies only to adults with axSpA. For brevity, we refer to b/tsDMARDs as “targeted therapies” throughout.

Target audience

This guideline is for health professionals in the UK who directly care for adults with axSpA (including but not limited to rheumatologists, rheumatology specialist nurses, allied health professionals, rheumatology specialty trainees, pharmacists), people living with axSpA and other stakeholders.

The areas the guideline does not cover:

• NSAIDs, glucocorticoids and conventional synthetic DMARDs.
• Treatment of enthesitis/spondylitis-related juvenile idiopathic arthritis.
• Axial disease in psoriatic arthritis [8].
• Safety of targeted therapies [9] or their use in pregnancy [10].
• Health economic considerations.

Stakeholder involvement

The guideline was developed by a multidisciplinary guideline working group (GWG), comprising and reflecting the views of individuals with lived experience of axSpA, rheumatologists, an ophthalmologist, a dermatologist, a gastroenterologist, a general practitioner, an epidemiologist, a specialist nurse, a consultant physiotherapist, a specialist pharmacist and the Chief Executive Office (CEO) of the patient-focused charity National Axial Spondyloarthritis Society (NASS). Drafting of the overarching principles was led by authors with lived experience of axSpA. Details of the GWG and their declared conflicts of interest are included at the end of this article and are available on the BSR website. The guideline was available for public consultation on the BSR website for a month prior to publication and was reviewed by the BSR Guideline Steering Group and external expert peer reviewers.

Rigour of development

This guideline was developed in accordance with the BSR Creating Guidelines Protocol (v5.4). The guideline and recommendations were underpinned by a systematic literature review.