2024 Thai Rheumatism Association Guideline for the Treatment of Axial Spondyloarthritis with Biologic and Targeted Synthetic Disease-Modifying Anti-Rheumatic Drugs

Objective: To provide rheumatologists with the decisions for the appropriate and standardized treatment of patients with axial spondyloarthritis (axSpA) with biologic disease-modifying antirheumatic drugs (bDMARD) and targeted synthetic DMARDs (tsDMARD), according to current evidence and expert opinion. Materials and Methods: The development process involved 46 rheumatologist representatives from medical schools, government hospitals, and private hospitals nationwide. Relevant clinical questions related to treatment initiation criteria, administration, evaluation, monitoring, and intensive treatment options were selected. The evidence was systematically identified and summarized. Quality of evidence was evaluated and ranked according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) scoring methodology. The recommendations were then proposed and voted on using the nominal group process. The input was collected from stakeholders through a public hearing. The final 13 recommendations were provided. Results: The guideline addresses the criteria for starting bDMARD/tsDMARD and details the first-line drugs for specific disease profiles, including predominantly axial involvement, predominantly peripheral joint involvement, and uveitis. It also addresses the management of patients with comorbid conditions such as tuberculosis, chronic hepatitis B, malignancy, and pregnancy. Additionally, it covers monitoring and follow-up procedures, alternative treatments for first-line treatment failures, tapering treatment after remission, and reinstitution of bDMARD/tsDMARD in case of flare-up. Conclusion: Thai Rheumatism Association has proposed a set of recommendations to outline concepts and provide guidance on the treatment of axSpA with bDMARD and tsDMARD for Thai rheumatologists.