Abstract
Purpose of review
Axial spondyloarthritis (axSpA) encompasses a broad disease spectrum, and the management landscape has expanded considerably over the past two decades. This review synthesizes the current evidence on pharmacological and non-pharmacological interventions in axSpA, addressing both symptom control and radiographic outcomes across drug classes and patient contexts.Recent findings
NSAIDs remain the cornerstone of first-line therapy, with emerging long-term cohort data suggesting a dose-response relationship between NSAID exposure and reduced radiographic spinal progression in radiographic disease. TNF inhibitors retain the most mature evidence base regarding radiographic progression, with longitudinal data associating TNFi exposure with slower mSASSS progression and suggesting that this effect may be partially uncoupled from inflammation as measured by ASDAS, particularly with earlier treatment initiation. IL-17 inhibitors demonstrate robust symptomatic efficacy, while two-year structural data show low radiographic progression, although a treatment-specific structural effect has not been established. JAK inhibitors provide effective symptom control, and longer-term radiographic data are now available, but controlled evidence demonstrating inhibition of structural progression remains lacking. Exercise therapy, supported by a recent systematic review and meta-analysis, improves disease activity, function, mobility, pain, and fatigue, with subgroup analyses showing significant BASFI improvement only for sessions lasting ≤60 minutes. Obesity is associated with greater disease activity and poorer response to TNF inhibitors. Symptom control is achievable across all major drug classes in axSpA. Evidence regarding radiographic progression is most mature for TNF inhibitors, more limited for IL-17 inhibitors, context-dependent for NSAIDs, and currently insufficient to establish structural modification with JAK inhibitors. Effective management requires integrating pharmacological and non-pharmacological strategies, including structured exercise as an evidence-based intervention, while recognizing obesity as a clinically relevant prognostic factor.