Dr Sizheng Steven Zhao, lead author of the 2025 British Society for Rheumatology guideline on managing axial spondyloarthritis, presents its practical recommendations on targeted therapies, multidisciplinary care and extra-musculoskeletal manifestations, discussed within a holistic treatment framework that emphasises shared decision-making and the ongoing role of non-pharmacological strategies.
Axial spondyloarthritis (axSpA) is a chronic, immune-mediated disease that primarily targets the spine and sacroiliac joints. It may also involve peripheral joints, entheses and extra-musculoskeletal manifestations, such as acute anterior uveitis, psoriasis and inflammatory bowel disease (IBD).1
Symptoms of axSpA typically start in early adulthood but diagnosis can take several years.2 Chronic inflammatory pain and stiffness are well recognised to have adverse effects on quality of life, social participation and mental health.3–5 The comorbidity burden is also higher than that of age-matched people without axSpA,6 which can influence treatment choice.
Since the publication of the 2017 British Society for Rheumatology axSpA guideline,7 pharmacological management has expanded from tumour necrosis factor inhibitors (TNFi) to include other biologic disease-modifying antirheumatic drugs (bDMARDs), targeted synthetic disease-modifying antirheumatic drugs (tsDMARDs) and treatment strategies such as drug tapering.
Targeted therapies and a holistic approach
Therapeutic options for treating extra-musculoskeletal manifestations as index conditions have similarly evolved. This increasingly complex therapeutic landscape forms the scope and context in which we updated the guideline in 2025.8
The guideline was developed by a multidisciplinary working group representing a broad range of perspectives, including individuals with lived experience of axSpA, as well as specialists in rheumatology, ophthalmology, dermatology, gastroenterology, epidemiology, nursing, physiotherapy and pharmacy, alongside the National Axial Spondyloarthritis Society.
Unlike European and US guidelines, we focused on targeted therapies, particularly pragmatic recommendations for their use in the presence of extra-musculoskeletal manifestations.
Although the guideline focuses on pharmacological therapies, non-pharmacological modalities such as physiotherapy, hydrotherapy, lifestyle interventions and patient education form the cornerstone of axSpA management. Pharmacological treatments should facilitate and enable physical activity, not replace it.
Diagnosis challenges and treatment response
Recent research has highlighted the challenges of diagnosing axSpA. For example, roughly one-third of the general population can have inflammatory and/or structural changes on their MRI report,9 and around a third of axSpA cases may not be axSpA when centrally adjudicated.10 This means that we must be open to re-evaluating the diagnosis, particularly when patients do not respond to multiple lines of therapy.
The guideline recommends the use of the AxSpA Disease Activity Score (ASDAS) for monitoring disease. Unlike the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), ASDAS is shown to correlate with radiographic progression.11,12 Definitions of high disease activity using ASDAS ≥ 2.1 or the BASDAI ≥ 4 usually coincide, but when discordant, the ASDAS definition better predicts treatment response.13,14
Adopting ASDAS should be straightforward for those already familiar with using the Disease Activity Score-28, which incorporates C-reactive protein levels and patient global assessment of health.
Supporting treatment decisions
There are only three classes of drugs for this condition, which may need many decades of treatment. Therefore, any treatment decisions should consider the overall number of available therapeutic options, adverse prognostic factors for disease progression and treatment response, as well as the extent of inflammatory disease activity.
The presence of extra-musculoskeletal manifestations should not trigger a reflex treatment decision. A more considered approach involving discussion with ophthalmologists, dermatologists and gastroenterologists is required where possible.
Monoclonal TNFi are preferred for uveitis, but a history of inactive uveitis is not a contraindication for other classes of drug. Monoclonal TNFi and Janus kinase inhibitors are preferred for IBD, but, again, a history of inactive IBD is not an absolute contraindication for other drugs.
Treating to a numerical target may lead to rapid cycling through available treatment options, while the leading treat-to-target TICOSPA trial did not achieve its primary outcome or the majority of secondary outcomes.15 Therapeutic targets should therefore be agreed upon with the person with axSpA, rather than being based solely on disease indices.
In sustained remission, increasing the dosing interval via therapeutic tapering can be considered. However, withdrawing therapy is invariably followed by a disease flare that cannot always be re-controlled.
Research recommendations and next steps
The axSpA multidisciplinary guideline working group proposed a range of research recommendations to address key evidence and identified the top 10 priorities.8
These include exploring non-pharmacological management options and conducting head-to-head clinical trials to compare the effectiveness of targeted therapies. Further research is needed into strategies for managing fatigue in axSpA, as well as the evidence supporting the sequential use of targeted therapies. The group also emphasised the importance of identifying criteria for initiating and predicting success in therapeutic tapering.
Additional priorities include improving the management of difficult-to-treat axSpA and clarifying the role of imaging in assessing treatment response. The effective use of patient-initiated follow-up was also identified as an area requiring further investigation.
Finally, the group emphasised the need for more evidence on the comparative safety of targeted therapies in axSpA populations and the safety and efficacy of combining targeted therapies in individuals with axSpA and extra-musculoskeletal manifestations.
Conclusion
The primary objective of treatment is to support patients with axSpA in leading healthy, fulfilling and productive lives. This is achieved by optimising health-related quality of life through the comprehensive management of all disease manifestations, preventing structural damage and preserving physical function. Also important are the goals of maintaining work productivity and promoting social participation.
Effective management should be a collaborative process, developed in partnership with the person living with axSpA. Treatment decisions must reflect an individual’s needs, goals and preferences, while also considering the resources available within the healthcare setting.
Finally, a multidisciplinary approach is essential, coordinated by a rheumatologist and supported by a team that can deliver holistic care. This includes both pharmacological and non-pharmacological interventions tailored to the individual’s overall health and disease profile.
Author
Sizheng Steven Zhao MBChB PhD
Clinical senior lecturer (associate professor) and consultant rheumatologist, University of Manchester
References
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- Zhao SS et al Diagnostic delay in axial spondyloarthritis: a systematic review and meta-analysis. Rheumatology (Oxford) 2021;60:1620–8.
- Hollick RJ et al. Outcomes and treatment responses, including work productivity, among people with axial spondyloarthritis living in urban and rural areas: a mixed-methods study within a national register. Ann Rheum Dis 2020;79:1055–62.
- Macfarlane GJ et al. Determining factors related to poor quality of life in patients with axial spondyloarthritis: results from the British Society for Rheumatology Biologics Register (BSRBR-AS). Ann Rheum Dis 2020;79:202–8.
- Zhao SS et al. The prevalence of depression in axial spondyloarthritis and its association with disease activity: a systematic review and meta-analysis. Arthritis Res Ther 2018;20.
- Zhao SS et al. Prevalence and impact of comorbidities in axial spondyloarthritis: systematic review and meta-analysis. Rheumatology (Oxford) 2020;59:iv47–57.
- Hamilton L et al. BSR and BHPR guideline for the treatment of axial spondyloarthritis (including ankylosing spondylitis) with biologics. Rheumatology 2017;56:313–6.
- Zhao SS et al. The 2025 British Society for Rheumatology guideline for the treatment of axial spondyloarthritis with biologic and targeted DMARDs. Rheumatology (Oxford) 2025;64:3242–54.
- Torgutalp M et al. Op0284 Frequency and Factors Associated with the Presence of Active Inflammatory and Structural Changes in the MRI of Sacroiliac Joints: Results from a Population-Based Study. Ann Rheum Dis 2024;83:116–7.
- Poddubnyy D et al. Pos0029 enhancing the diagnostic accuracy and avoiding overdiagnosis in axial spondyloarthritis through central evaluation of imaging: improve-axSpA, a nationwide telemedicine project. Ann Rheum Dis 2024;83:476–7.
- Ramiro S et al. Higher disease activity leads to more structural damage in the spine in ankylosing spondylitis: 12-year longitudinal data from the OASIS cohort. Ann Rheum Dis 2014;73:1455–61.
- Poddubnyy D et al. High disease activity according to the Ankylosing Spondylitis Disease Activity Score is associated with accelerated radiographic spinal progression in patients with early axial spondyloarthritis: results from the GErman SPondyloarthritis Inception Cohort. Ann Rheum Dis 2016;75:2114–8.
- Fagerli KM et al. Selecting patients with ankylosing spondylitis for TNF inhibitor therapy: comparison of ASDAS and BASDAI eligibility criteria. Rheumatology (Oxford) 2012;51:1479–83.
- Marona J et al. Eligibility criteria for biologic disease-modifying antirheumatic drugs in axial spondyloarthritis: going beyond BASDAI. RMD Open 2020;6:e001145.
- Molto A et al. Efficacy of a tight-control and treat-to-target strategy in axial spondyloarthritis: results of the open-label, pragmatic, cluster-randomised TICOSPA trial. Ann Rheum Dis 2021;80:1436–44.
