Since the 2019 guideline on the treatment of axial spondyloarthritis was published, the field has advanced significantly, reshaping clinical practice and prompting an update in 2026.
During 2026 ACR/SPARTAN/SAA Guidelines for the Treatment of Axial Spondyloarthritis (axSpA) and Juvenile Axial Spondyloarthritis (J-axSpA), a panel of experts will discuss the updated treatment algorithms and highlight key segments using a case-based format. The session will be held on Monday, November 9, from 10–11:30 a.m., in Room W415D of the Orange County Convention Center. A recording of the session will be available to registered participants of ACR Convergence 2026 for on-demand viewing.
“These are some of the most ambitious guidelines that the American College of Rheumatology (ACR) has released on a topic. So many of the prior guidelines are limited to pharmacologic management with limited recommendations around non-pharmacologic therapies, but we tried to be comprehensive and extremely expansive in our approach,” said Liron Caplan, MD, PhD, Associate Professor at the University of Colorado School of Medicine. “A large interdisciplinary team contributed to these guidelines, so they really do represent the opinions of the experts, both within rheumatology and in the disciplines that we rely on for co-management of these complex diseases.”
In the 2026 Axial Spondyloarthritis Adult Guideline, the sequencing of therapies has been revised so that tumor necrosis factor (TNF) inhibitors and interleukin-17 (IL-17) inhibitors are now equally recommended as initial biologic disease-modifying anti-rheumatic drugs (DMARDs), with Janus kinase (JAK) inhibitors reserved for those who fail IL-17 or TNF inhibitors. There’s also a recommendation allowing providers to bypass nonsteroidal anti-inflammatory drugs for patients with poor prognostic features. Additionally, for patients who have failed multiple classes of therapy, the experts now conditionally recommend the use of existing agents above the U.S. Food and Drug Administration (FDA)-indicated dose for axSpA and j-axSpa, acknowledging that the dose used safely in related conditions sometimes exceeds the dose in spondyloarthritis. Treatment-resistant patients may also warrant dual biologic and targeted synthetic DMARD therapy.
“Guidelines are there to guide providers about what steps they can take to help patients in their journey. But in the end, it’s an individualized approach, and we need to listen to patients. We need to talk to them about the options we have, and then we can decide together,” said Mohamad Bittar, MD, MS, Associate Professor at Oregon Health & Science University. “I want attendees to know that the guidelines are a powerful tool they can use to help providers and patients access medical care. If, for example, a provider and patient choose a medication and insurance denies it, they can use the guideline to support an appeal and help patients get the medication or treatment they need.”
With the 2026 update, the guideline now includes specific recommendations for juveniles, and earlier versions did not. Matthew Stoll, MD, PhD, MSCS, Professor at the University of Alabama at Birmingham, will introduce the juvenile guidelines and summarize the differences and similarities between the juvenile and the adult versions of the guideline.
“One of the most important differences is in diagnosis,” Dr. Stoll noted. “For the evaluation of axSpA in adults, the first diagnostic test is usually an X-ray. In children, we recommend MRI as a first diagnostic test over X-ray. The X-ray is generally not helpful in the assessment of J-axSpA, and it certainly does not capture any findings of active inflammation. While insurers often require X-ray before approving an MRI, I hope that these guidelines will allow us to move straight to getting an MRI when we suspect the diagnosis.”
THERE’S STILL TIME TO JOIN US
If you haven’t registered for ACR Convergence 2026, you can still register on-site at the Orange County Convention Center in Orlando, Florida, through November 11. All registered participants receive on-demand access to scientific sessions through September 30, 2027.
