Major update in axial spondyloarthritis care expands biologic and JAK pathways

Clinical Takeaway: Start with NSAIDs for most patients, but move early to TNF or IL-17 inhibitors in those with inadequate response or high-risk disease; choose therapy based on comorbidities and switch mechanisms if treatment fails.

The 2026 update to the ACR/SAA/SPARTAN guidelines delivers a comprehensive overhaul of axial spondyloarthritis (axSpA) management—updating adult recommendations last issued in 2019 and introducing a first-ever dedicated guideline for children and adolescents. Across both populations, the guidance emphasizes individualized care and shared decision-making in the setting of limited high-quality evidence.

“Axial spondyloarthritis is a complex, lifelong condition that requires nuanced and individualized management,” said lead author Liron Caplan, MD, PhD, highlighting the guideline’s focus on aligning treatment with patient preferences and disease features.

For diagnosis, imaging pathways diverge by age: adults should undergo sacroiliac joint radiographs first, followed by MRI if inconclusive, while MRI without contrast is preferred upfront in pediatric patients.

Pharmacologic treatment remains stepwise but more clearly defined. NSAIDs are strongly recommended as first-line therapy for most patients, with continuous use preferred in active disease. Escalation to biologic or targeted synthetic DMARDs is advised for patients with persistent activity or high-risk features such as elevated CRP or structural damage.

Among advanced therapies, TNF inhibitors and IL-17 inhibitors are now considered equivalent first-line biologic options, while JAK inhibitors are recommended but generally reserved for use after these agents. The guidelines explicitly recommend against routine use of conventional synthetic DMARDs (e.g., methotrexate, sulfasalazine) for axial disease in the absence of peripheral arthritis or extra-musculoskeletal manifestations (EMMs).

Treatment selection should be tailored to comorbid EMMs: monoclonal TNF inhibitors are preferred in patients with uveitis or inflammatory bowel disease, whereas IL-17 inhibitors are favored in those with psoriasis. If initial biologic therapy fails, switching to a different mechanism of action is recommended over cycling within the same class.

For refractory disease, clinicians are encouraged to reassess for noninflammatory causes of symptoms (e.g., nociplastic pain, adherence issues). In select cases, dose escalation or dual targeted therapy may be considered.

The guideline also reinforces key “don’ts”: avoid systemic glucocorticoids, opioids, IL-23 inhibitors, and several non-indicated biologics; do not abruptly discontinue effective biologic therapy due to flare risk; and avoid routine imaging surveillance in stable disease.

Nonpharmacologic strategies remain essential. Physical therapy—particularly active, supervised exercise—is strongly recommended, along with patient education, weight optimization, and cardiovascular risk screening.

Pediatric recommendations broadly align with adult care but emphasize earlier MRI-based diagnosis and careful long-term treatment planning. The introduction of these pediatric-specific guidelines marks a significant step toward earlier recognition and tailored therapy in younger patients.

What’s changed

• First dedicated guideline for juvenile axSpA, including MRI-first diagnostic approach
• TNF inhibitors and IL-17 inhibitors now positioned as equivalent first-line biologics
• JAK inhibitors formally incorporated, but not first-line among advanced therapies
• Greater emphasis on switching mechanisms (rather than cycling within class) after biologic failure
• More explicit guidance on EMM-driven treatment selection (uveitis/IBD vs psoriasis)
• Conditional support for dual-targeted therapy in refractory cases
• Stronger recommendations against csDMARDs for isolated axial disease and against IL-23 inhibitors
• Continued emphasis on tapering—not stopping—therapy in remission

Sources:

American College of Rheumatology; Spondylitis Association of America; SPARTAN. 2026. Arthritis & Rheumatology / Arthritis Care & Research (in submission). 2026 Update of the ACR/SAA/SPARTAN Recommendations for the Treatment of Axial Spondyloarthritis in Adults and Children/Adolescents; American College of Rheumatology. 2026 June 24. American College of Rheumatology [Press release]. New Guidelines Advance Treatment of Axial Spondyloarthritis in Adults and Youth