Upadacitinib in Axial Spondyloarthritis Treatment

Introduction to Upadacitinib

The American College of Rheumatology and the European League Against Rheumatism recommend upadacitinib for the treatment of active axial spondyloarthritis, including ankylosing spondylitis and non-radiographic axial SpA, particularly after inadequate response to NSAIDs or biologic DMARDs 1, 2, 3, 4

Upadacitinib has been proven effective and is indicated for ankylosing spondylitis (AS) treatment, distinguishing it from other JAK inhibitors like filgotinib which lacks this indication 1, 2, 3, 4
The 2022 GRAPPA guidelines extrapolate evidence from ankylosing spondylitis trials to recommend JAK inhibitors (including upadacitinib, tofacitinib, and filgotinib) for axial psoriatic arthritis based on phase II and phase II-III RCT data 5, 6

TNF inhibitors remain first-line for most patients, but upadacitinib 15 mg once daily is an appropriate alternative, particularly when TNF inhibitors are contraindicated 1, 2, 3
After anti-TNF failure, swapping to JAK inhibitors including upadacitinib is recommended with 91% expert agreement 2, 3, 4
JAK inhibitors can be considered with 95-100% expert agreement depending on clinical context 1, 2, 3, 4

TNF inhibitors (infliximab, adalimumab) remain first-line for active axial SpA with active IBD 1, 2, 4
After anti-TNF failure, JAK inhibitors can be considered with 95% agreement 1, 2, 4
Upadacitinib has dual indication: approved by EMA for both Crohn's disease and ankylosing spondylitis, making it particularly suitable for this population 1, 2, 3, 4

Active serious infections require treatment before initiating upadacitinib 7
Screen for latent tuberculosis, hepatitis B and C before initiation 7, 8
Baseline monitoring should include complete blood count with differential, liver enzymes, and lipid panel 7
Sulfasalazine and methotrexate are not recommended for purely axial disease due to lack of efficacy 2, 4
IL-17 inhibitors are absolutely contraindicated in active IBD as they can exacerbate Crohn's disease 8
Etanercept is ineffective in Crohn's disease and can trigger new-onset disease 4
Ongoing monitoring for signs of infection, particularly herpes zoster 7
Monitor for venous thromboembolism signs 7
Serial complete blood counts to assess for cytopenias 7
Do not automatically discontinue unless serious infection or malignancy is confirmed 7