Therapeutic management of axial spondyloarthritis: summary of 2024 update of the Spanish clinical practice guideline (ESPOGUIA)

Abstract

Axial spondyloarthritis (axSpA) is a chronic inflammatory rheumatic disease associated with significant morbidity and impaired quality of life. Rapid advances in diagnosis, monitoring, and especially treatment over the past decade have increased the complexity of axSpA management and contributed to variability in clinical practice. To address this need, the Spanish Society of Rheumatology (SER) has developed an updated version of ESPOGUÍA, its clinical practice guideline for spondyloarthritis. This review summarizes the updated recommendations. A multidisciplinary panel (including rheumatologists, other medical specialists, nurses, physiotherapists, methodologists, and patients) formulated key clinical questions using the PICO framework. Systematic literature reviews covering the period 2018–2023 were conducted across major databases. Evidence quality and strength of recommendations were assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. When evidence was insufficient, recommendations were formulated through a structured deliberative consensus process using the GRADE Evidence-to-Decision framework. Patient representatives actively contributed throughout the process, and the draft guideline underwent public consultation. ESPOGUÍA provides evidence-based recommendations for the management of adult patients with axSpA, focusing on pharmacological and non-pharmacological interventions. The guideline addresses the use of biologic and targeted synthetic disease-modifying antirheumatic drugs, prognostic factors for treatment response and radiographic progression, management of treatment failure, and strategies for treatment optimization, including dose tapering. Special attention is given to extra-musculoskeletal manifestations such as uveitis, inflammatory bowel disease, and psoriasis. Non-pharmacological approaches—including physical activity, smoking cessation, weight management, and nurse-led education—are emphasized as integral components of comprehensive care. ESPOGUÍA 2024 offers a comprehensive, evidence-based framework to support harmonized and patient-centered management of axSpA in Spain. By integrating recent therapeutic advances and multidisciplinary perspectives, the guideline aims to reduce variability in clinical practice, improve outcomes, and enhance quality of life for patients with axSpA, while also identifying key areas for future research.