The American College of Rheumatology (ACR), Spondylitis Association of America (SAA), and Spondyloarthritis Research and Treatment Network (SPARTAN) have released the 2026 update to their recommendations for the treatment of axial spondyloarthritis (axSpA) in adults, accompanied by a new companion guideline addressing children and adolescents with juvenile axSpA for the first time.¹ Both guidelines were approved by the ACR Board of Directors on May 31, 2026; full manuscripts are expected to be submitted to Arthritis & Rheumatology and Arthritis Care & Research but have not yet been peer-reviewed or published.
The 2026 update revises the prior 2019 ACR/SAA/SPARTAN guideline, expanding pharmacologic recommendations and adding guidance on nociplastic pain, imaging strategy, bone health, and comorbidity management.¹ ² A notable change from prior guidance is the elevation of JAK inhibitors (tofacitinib, upadacitinib) from conditional to strong recommendation in the second-line setting for adults.
Key Takeaways
The 2026 ACR/SAA/SPARTAN guideline updates the 2019 axSpA recommendations and introduces the first dedicated guideline for juvenile axSpA
JAK inhibitors (tofacitinib, upadacitinib) are now strongly recommended for active axSpA, elevated from conditional; TNFi and IL-17i remain conditionally preferred over JAKi when selecting among classes
IL-23 inhibitors carry a strong recommendation against use in axSpA and axial PsA in both adults and children
New recommendations address nociplastic pain, with opioids strongly discouraged and gabapentinoids, CBT, and SSRIs/SNRIs conditionally recommended in adults
Most recommendations are graded at low to very low evidence; the ACR emphasizes shared decision-making throughout
Pharmacologic recommendations for active axSpA: biologic and targeted synthetic DMARDs
The 2026 guideline continues to position TNF inhibitors (TNFi) and IL-17 inhibitors (IL-17i) as equally preferred initial biologic DMARDs, with a conditional recommendation against favoring one class over the other.¹ Both classes carry strong recommendations and moderate-to-high evidence. Neither secukinumab nor ixekizumab is favored over the other within the IL-17i class.
JAK inhibitors now carry a strong recommendation for use in active axSpA, supported by moderate evidence, representing a meaningful shift from the conditional language in prior guidance.¹ The guideline maintains a conditional recommendation in favor of TNFi and IL-17i over JAKi when choosing between classes, reflecting a preference order rather than exclusion of JAKi. IL-23 inhibitors carry a strong recommendation against use in axSpA, including axial psoriatic arthritis; this applies equally to adults and the new pediatric guideline.
For patients failing 2 or more therapeutic classes, the guideline advises rheumatologists to re-evaluate for reasons of non-response before switching agents, explicitly naming non-adherence and nociplastic pain as considerations. Dose escalation above FDA-approved maximum dosing and dual-targeted therapy are conditionally recommended in select refractory cases. Conventional synthetic DMARDs (methotrexate, sulfasalazine, hydroxychloroquine, azathioprine, leflunomide, apremilast) carry conditional recommendations against use in the absence of extra-musculoskeletal manifestations (EMMs).
New recommendations on nociplastic pain, imaging, EMMs, and pediatric axSpA
The 2026 update introduces a dedicated section on axSpA complicated by nociplastic pain. Gabapentinoids, SSRIs/SNRIs, muscle relaxants, and cognitive behavioral therapy are all conditionally recommended in adults; opioid analgesics carry a strong recommendation against use. In the juvenile guideline, the recommendations for nociplastic pain are considerably more restrictive, with strong recommendations against gabapentinoids, SSRIs/SNRIs, and muscle relaxants in children and adolescents.
On imaging, the guidelines recommend against routine scheduled spine or pelvis radiographs at fixed intervals in both active and inactive disease across both age groups. For adults with unclear disease activity on a biologic or targeted synthetic DMARD, spinal or sacroiliac joint (SIJ) MRI carries a strong recommendation over PET scan. AP pelvis radiograph remains the preferred initial imaging modality for suspected axSpA in adults, while SIJ MRI without contrast is strongly preferred in children and adolescents.
FAQ
What changed in the 2026 ACR axSpA guideline compared to 2019?
The 2026 update elevates JAK inhibitors to a strong recommendation in the second-line setting, introduces a new section on nociplastic pain management, expands imaging guidance, and adds the first-ever ACR recommendations for children and adolescents with juvenile axSpA.
Are JAK inhibitors now preferred over biologics in axSpA?
No. TNFi and IL-17i remain conditionally preferred over JAKi, but JAKi now carry a strong recommendation for use in active axSpA, up from conditional in prior guidance.
What is the recommendation for IL-23 inhibitors in axSpA?
IL-23 inhibitors carry a strong recommendation against use in both axSpA and axial psoriatic arthritis in adults, a recommendation also reflected in the new juvenile axSpA guidelines.
EMM-driven treatment selection is unchanged in structure but expanded. Active uveitis or inflammatory bowel disease continues to favor TNF monoclonal antibodies, while psoriasis favors IL-17i. New co-management good practice statements require multidisciplinary involvement with gastroenterology, ophthalmology, and dermatology when relevant EMMs are present. For the first time, the adult guideline includes a conditional recommendation against cannabinoids (THC and CBD) for pain in axSpA, graded at very low evidence.
The pediatric guideline represents the first ACR/SAA/SPARTAN guidance dedicated to juvenile axSpA. TNFi and IL-17i carry strong recommendations with moderate-to-high evidence; JAKi carries a conditional recommendation at moderate evidence, one grade below the adult recommendation. Strong recommendations against opioids and cannabinoids apply in children and adolescents. Spinal manipulation carries a strong recommendation against use in both age groups.
Both guidelines acknowledge predominantly low to very low evidence across most recommendations, and the ACR emphasizes shared decision-making between rheumatologists and patients or families given these limitations.¹
REFERENCES:
American College of Rheumatology. 2026 Update of the American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network Recommendations for the Treatment of Axial Spondyloarthritis in Adults and Children/Adolescents. Guideline summary approved May 31, 2026. Accessed June 2026. https://www.rheumatology.org/
Ward MM, Deodhar A, Gensler LS, et al. 2019 Update of the American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network recommendations for the treatment of ankylosing spondylitis and nonradiographic axial spondyloarthritis. Arthritis Rheumatol. 2019;71(10):1599-1613. doi:10.1002/art.41042
