Tunisian recommendations of good practice for the therapeutic management of spondyloarthritis (excluding biological treatment).

Aim: To develop good practice recommendations (GPR) for the therapeutic management of patients with spondyloarthritis (SpA), including psoriatic arthritis.

Methods: Following standardised procedures, a systematic review of the literature was carried out on non-pharmacological and non-biological pharmacological treatments for SpA. The review was based on questions defined by a working group of 15 rheumatologists. The data was evaluated at group meetings, which led to the drafting of recommendations, the assignment of a grade to each recommendation and the determination of the level of agreement between the experts.

Results: A general principle and 11 recommendations were developed. The recommendations focus on treatment modalities, taking into account the dominant phenotype (axial, articular peripheral, enthesitic peripheral) and extra-articular manifestations (psoriasis, chronic inflammatory bowel disease (IBD)). The first recommendation concerns therapeutic patient education. Recommendations 2 to 4 focus on NSAIDs as the first-line pharmacological treatment for the various presentations of the disease, with the exception of those associated with IBD, as well as their prescribing modalities. Recommendation 5 deals with analgesics. Recommendation 6 limits the use of glucocorticoids to symptomatic peripheral arthritis and advises against their long-term use. Recommendation 7 deals with radioisotope synoviorthesis for refractory arthritis of the hips and knees. Conventional Synthetic Disease-Modifying AntiRheumatic Drugs (csDMARDs) are not recommended for SpA which is axial, enthesitic or involves dactylitis (recommendation 8). JAK inhibitors are recommended for axial SpA and for joint and skin involvement of psoriatic arthritis in failure of symptomatic treatment, csDMARDs and/or bDMARDs (recommendation 9). The latest recommendations (10-11) concern physical and surgical treatment respectively.

Conclusion: These GPR provide a summary of the current state of the literature, with the aim of optimising the management of patients with SpA, thereby improving the quality and safety of care with a better medico-economic approach. Efforts must be made to apply, implement and communicate these recommendations.