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Objectives: The Assessment of SpondyloArthritis International Society (ASAS) aimed to develop a set of quality standards (QS) to help improve the quality of healthcare provided to adult patients affected by axial spondyloarthritis (axSpA) worldwide., Methods: An ASAS task force developed a set of QS using a stepwise approach. First, key areas for quality improvement were identified, discussed, rated and agreed on. Thereafter, areas were prioritised and statements for the most important key areas were phrased on consensus. Appropriate quality measures were defined to allow quantification of the QS at the community level., Results: The ASAS task force, consisting of 20 rheumatologists, two physiotherapists and two patients, selected and proposed 34 potential key areas for quality improvement which were then commented by 140 ASAS members and patients. Within that process three new key areas came up, which led to a re-evaluation of all 37 key areas by 120 ASAS members and patients. Five key areas were identified as most important to determine quality of care: referral including rapid access, rheumatology assessment, treatment, education/self-management and comorbidities. Finally, nine QS were agreed on and endorsed by the whole ASAS membership., Conclusions: ASAS successfully developed the first set of QS to help improving healthcare for adult patients with axSpA. Even though it may currently not be realistic to achieve the QS in all healthcare systems, they provide high-quality of care framework for patients with axSpA that should be aimed for., Competing Interests: Competing interests: AB received research grants to her department from Abbvie and Celgene and honoraria for lectures or consulting fees form UCB, Janssen, Sandoz, Novartis and Eli-Lilly. JB: honoraria for talks, advisory boards, paid consultancies and grants from studies from Abbvie, Amgen, BMS, Boehringer, Celgene, Celltrion, Centocor, Chugai, EBEWE Pharma, Medac, MSD (Schering-Plough), Mundipharma, Novartis, Pfizer (Wyeth), Roche, Sanofi-Aventis, UCB. PC: honoraria for talks, advisory boards, paid consultancies from Celgene, MSD (Schering-Plough), Novartis, Pfizer (Wyeth), Roche, Sanofi-Aventis, UCB. MD: honoraria for lectures and advisory board meetings for Pfizer, Abbvie, Merck, UCB, Lilly, Novartis. LG research grants: Pfizer, UCB, Lilly, Bristol-Myers Squibb; honoraria for lectures and advisory board meetings from AbbVie, Amgen, Biogen, Celgene, Janssen, Lilly, MSD, Novartis, Pfizer, Sandoz, Sanofi-Aventis, UCBU. UK: received grant and research support and consultancy fees from AbbVie, Biogen, Chugai, Eli Lilly, Grünenthal, Janssen, MSD, Novartis, Pfizer, Roche and UCB. RBML: honoraria for lectures and advisory board meetings for AbbVie, Celgene, Galapagos, Janssen, Lilly, Novartis, Pfizer, UCBP. PMM has received consulting/speaker’s fees from Abbvie, BMS, Celgene, Janssen, MSD, Novartis, Pfizer, Roche and UCB. HM-O: grants from Janssen, Novartis. Speaking, honoraria from Abbvie, Celgene, Eli-Lilly, Janssen, Novartis, Pfizer and UCB. AM: honoraria for lectures and advisory board meetings for AbbVie, BMS, Janssen, MSD, Novartis, Sanofi, Pfizer and UCB.VN-C: consultancy/speaker/research grants from: Abbvie, BMS, Lilly, MSD, Novartis, Pfizer, Roche, UCB. educational/research grants: SAR, SER, SORCOM, EULAR, ASAS. MR: honoraria for presentations or advisory board meetings from Abbvie, Celgene, BMS, Janssen, Lilly, MSD, Novartis, Pfizer, UCB. PS-B: honoraria for presentations or advisory board meetings from Abbvie, Boehringer Ingelheim, Janssen, Novartis, UCB. GS: honoraria for lectures and/or advisory board meetings from Abbvie, Lilly, Novartis, Sanofi, Roche. DvdH: consulting fees AbbVie, Amgen, Astellas, AstraZeneca, BMS, Boehringer Ingelheim, Celgene, Daiichi, Eli-Lilly, Galapagos, Gilead, Glaxo-Smith-Kline, Janssen, Merck, Novartis, Pfizer, Regeneron, Roche, Sanofi, Takeda, UCB Pharma. Director of Imaging Rheumatology AvT received research grants from Pfizer, Abbvie, UCB, Novartis and Biogen and consulting fees from Novartis, Jansen-Cilag, Pfizer, MW: consulting fees from Novartis, Lilly, UCB., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Therapeutic targets have been defined for axial and peripheral spondyloarthritis (SpA) in 2012, but the evidence for these recommendations was only of indirect nature. These recommendations were re-evaluated in light of new insights. Based on the results of a systematic literature review and expert opinion, a task force of rheumatologists, dermatologists, patients and a health professional developed an update of the 2012 recommendations. These underwent intensive discussions, on site voting and subsequent anonymous electronic voting on levels of agreement with each item. A set of 5 overarching principles and 11 recommendations were developed and voted on. Some items were present in the previous recommendations, while others were significantly changed or newly formulated. The 2017 task force arrived at a single set of recommendations for axial and peripheral SpA, including psoriatic arthritis (PsA). The most exhaustive discussions related to whether PsA should be assessed using unidimensional composite scores for its different domains or multidimensional scores that comprise multiple domains. This question was not resolved and constitutes an important research agenda. There was broad agreement, now better supported by data than in 2012, that remission/inactive disease and, alternatively, low/minimal disease activity are the principal targets for the treatment of PsA. As instruments to assess the patients on the path to the target, the Ankylosing Spondylitis Disease Activity Score (ASDAS) for axial SpA and the Disease Activity index for PSoriatic Arthritis (DAPSA) and Minimal Disease Activity (MDA) for PsA were recommended, although not supported by all. Shared decision-making between the clinician and the patient was seen as pivotal to the process. The task force defined the treatment target for SpA as remission or low disease activity and developed a large research agenda to further advance the field., Competing Interests: Competing interests: DA served as a consultant and/or speaker for Abbvie, Astra-Zeneca, BMS, Janssen, Medac, MSD, Pfizer, Roche, UCB and received grant support from BMS. XB has served as consultant and/or speaker for Abbvie, BMS, Celgene, Chugai, Janssen, Novartis, Pfizer, UCB. NB has received consultancy fees for work commissioned by Grünenthal, Lilly, Janssen, PfizerLaura Coates has received research funding from Abbvie and Janssen and honoraria from Abbvie, Amgen, BMS, Celgene, Janssen, Lilly, MSD, Novartis, Pfizer, Sun Pharma, UCBMaxime Dougados has participated as a speaker in symposia or as an advisor in boards organized by Pfizer, Abbvie, Ucb, Merck, Amgen, Novartis, Lilly, Bms, Roche and his department has received research grants from Pfizer, Abbvie, Ucb, Merck, Amgen, Novartis, Lilly, Bms, Roche. Laure Gossec has received honoraria or research funding from Abbvie, BMS, Celgene, Janseen, MSD, Novartis, Pfizer, Roche and UCB. PE has undertaken clinical trials and provided expert advice to Pfizer, MSD, Abbvie, BMS, UCB, Roche, Novartis, Samsung, Sandoz and Lilly. OF reports grants and personal fees from Novartis, personal fees from Pfizer, personal fees from Lilly, personal fees from Cellgene, grants and personal fees from Abbvie, personal fees from Janssen, personal fees from UCB, outside the submitted work. AK has served as consultant and/or performed clinical research for Abbvie, Amgen, Celgene, Janssen, Novartis, UCB. PMM has received consultancy/speaker’s fees from AbbVie, Centocor, Janssen, Merck, Novartis, Pfizer and UCB. AM has received honoraria from Abbvie, MSD and UCBDP has received Grant/research support from: AbbVie, MSD, Novartis, Pfizer, has honoraria/speaker fees from AbbVie, BMS, Boehringer, Janssen, Lilly, MSD, Novartis, Pfizer, Roche, and UCB. MR has received honoraria/ consultancies from Abbvie, BMS, Celgene, Chugai/Roche, Janssen, MSD, Novartis, Pfizer, UCB. JS has received grant support from and/or provided expert advice to Abbvie, Amgen, Astra-Zeneca, BMS, Boehringer-Ingelheim, Celgene, Celltrion, Gilead, Glaxo, Iltoo, Janssen, Lilly, Pfizer, MSD, Roche, Samsung, Novartis-Sandoz, UCB. TS has received honoraria from Abbvie, Janssen, MSD, Novartis and Roche and grant support from Abbvie. FVB has received speaker and/or consultancy fees from AbbVie, Celgene, Janssen,Lilly, MSD, Novartis, Pfizer and UCB. DH has received consulting fees Afrom bbVie, Amgen, Astellas, AstraZeneca, BMS, Boehringer Ingelheim, Celgene, Daiichi, Eli-Lilly, Galapagos, Gilead, Glaxo-Smith-Kline, Janssen, Merck, Novartis, Pfizer, Regeneron, Roche, Sanofi, Takeda, UCB, and is Director of Imaging Rheumatology bv. MW has received consulting fees for lectures or advisory board meetings from Abbvie, BMS, Celgene, Eli Lilly, Novartis and Roche., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

To update and integrate the recommendations for ankylosing spondylitis and the recommendations for the use of tumour necrosis factor inhibitors (TNFi) in axial spondyloarthritis (axSpA) into one set applicable to the full spectrum of patients with axSpA. Following the latest version of the European League Against Rheumatism (EULAR) Standardised Operating Procedures, two systematic literature reviews first collected the evidence regarding all treatment options (pharmacological and non-pharmacological) that were published since 2009. After a discussion of the results in the steering group and presentation to the task force, overarching principles and recommendations were formulated, and consensus was obtained by informal voting. A total of 5 overarching principles and 13 recommendations were agreed on. The first three recommendations deal with personalised medicine including treatment target and monitoring. Recommendation 4 covers non-pharmacological management. Recommendation 5 describes the central role of non-steroidal anti-inflammatory drugs (NSAIDs) as first-choice drug treatment. Recommendations 6-8 define the rather modest role of analgesics, and disprove glucocorticoids and conventional synthetic disease-modifying antirheumatic drugs (DMARDs) for axSpA patents with predominant axial involvement. Recommendation 9 refers to biological DMARDs (bDMARDs) including TNFi and IL-17 inhibitors (IL-17i) for patients with high disease activity despite the use (or intolerance/contraindication) of at least two NSAIDs. In addition, they should either have an elevated C reactive protein and/or definite inflammation on MRI and/or radiographic evidence of sacroiliitis. Current practice is to start with a TNFi. Switching to another TNFi or an IL-17i is recommended in case TNFi fails (recommendation 10). Tapering, but not stopping a bDMARD, can be considered in patients in sustained remission (recommendation 11). The final two recommendations (12, 13) deal with surgery and spinal fractures. The 2016 Assessment of SpondyloArthritis international Society-EULAR recommendations provide up-to-date guidance on the management of patients with axSpA., Competing Interests: Competing interests: DvdH received consulting fees from AbbVie, Amgen, Astellas, AstraZeneca, BMS, Boeringer Ingelheim, Celgene, Daiichi, Eli-Lilly, Galapagos, Gilead, Janssen, Merck, Novartis, Pfizer, Regeneron, Roche, Sanofi-Aventis, UCB and is Director of Imaging Rheumatology BV. RL received consulting fees from AbbVie, Ablynx, Amgen, AstraZeneca, Bristol-Myers Squibb, Celgene, Janssen, Galapagos, GlaxoSmithKline, Novartis, Novo-Nordisk, Merck, Pfizer, Rhoche, Schering-Plough, TiGenix, UCB and is Director of Rheumatology Consultancy BV. XB received consulting fees and research grants from AbbVie, Bristol-Myers Squibb, Celgene, Janssen, Novartis, Pfizer, Roche, MSD and UCB. FVdB received consulting and/or speaker fees from AbbVie, BMS, Celgene, Eli-Lilly, Janssen, Merck, Novartis, Pfizer and UCB. AC received consulting fees from AbbVie, Celgene, Eli-Lilly, Janssen-Cilag, Merck Sharp & Dohme, Novartis, Pfizer and UCB. MD received consulting fees from AbbVie, BMS, Boeringer Ingelheim, Celgene, Eli-Lilly, Galapagos, Janssen, Merck, Novartis, Pfizer, Regeneron, Roche, Sanofi-Aventis and UCB. FvG received consulting fees from Pfizer, MSD, AbbVie and Novartis. PG received consulting fees from AbbVie and Roche. IvdH-B received consulting fees from AbbVie, UCB and MSD and received unrestricted grants for investigator initiated studies from MSD, Pfizer and AbbVie. RDI received consulting fees from Amgen, Janssen, AbbVie, Novartis. UK received consultancy fees as well as grant and research support from AbbVie, Chugai, MSD, Novartis, Pfizer, Roche and UCB. TKK received consulting fees from AbbVie, Biogen, BMS, Boehringer Ingelheim, Celltrion, Eli-Lilly, Epirus, Janssen, Merck-Serono, MSD, Mundipharma, Novartis, Oktal, Orion Pharma, Hospira/Pfizer, Roche, Sandoz and UCB Pharma. PM received speaker/consulting fees from AbbVie, Centocor, Janssen, MSD, Novartis and Pfizer. HM-O received consulting fees from AbbVie, Celgene, Janssen, MSD, Novartis, Pfizer and UCB and grants from Janssen and Pfizer. AM received consulting fees and/or grants from AbbVie, Merck Pfizer and UCB. VN-C received consulting fees from AbbVie, BMS, Novartis, Pfizer, Roche and UCB. SO received consulting fees, speaking fees and/or honoraria from AbbVie, Pfizer, UCB, Merck Sharp & Dohme and Novartis. FMP-S received consulting fees from AbbVie, Celgene, Janssen, Novartis, Pfizer, Roche, Merck Sharp & Dohme, UCB, Biogen. JR received consulting fees from Janssen and is a participant in clinical trials of Janssen and Eli-Lilly. MR received consulting or speaking fees from AbbVie, Bristol-Myers Squibb, Celgene, Chugai, Janssen, Novartis, Merck, Pfizer, Roche, UCB. JS received consulting fees from AbbVie, Boeringer Ingelheim, Eli-Lilly, Galapagos, Janssen, Merck, Novartis, Pfizer, Roche, UCB. PS-B received consulting fees from AbbVie, Janssen, Novartis, Pfizer, Roche, UCB. JB received research grants, honoraria, speaker fees and consultancy payments from AbbVie (Abbott), Amgen, Biogen, Boehringer Ingelheim, BMS, Celgene, Celltrion, Centocor, Chugai, EBEWE Pharma, Epirus, Hospira, Janssen, Medac, MSD (Schering-Plough), Mundipharma, Novartis, Pfizer (Wyeth), Roche, Sanofi-Aventis and UCB., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Background: Therapeutic targets have been defined for diseases like diabetes, hypertension or rheumatoid arthritis and adhering to them has improved outcomes. Such targets are just emerging for spondyloarthritis (SpA)., Objective: To define the treatment target for SpA including ankylosing spondylitis and psoriatic arthritis (PsA) and develop recommendations for achieving the target, including a treat-to-target management strategy., Methods: Based on results of a systematic literature review and expert opinion, a task force of expert physicians and patients developed recommendations which were broadly discussed and voted upon in a Delphi-like process. Level of evidence, grade and strength of the recommendations were derived by respective means. The commonalities between axial SpA, peripheral SpA and PsA were discussed in detail., Results: Although the literature review did not reveal trials comparing a treat-to-target approach with another or no strategy, it provided indirect evidence regarding an optimised approach to therapy that facilitated the development of recommendations. The group agreed on 5 overarching principles and 11 recommendations; 9 of these recommendations related commonly to the whole spectrum of SpA and PsA, and only 2 were designed separately for axial SpA, peripheral SpA and PsA. The main treatment target, which should be based on a shared decision with the patient, was defined as remission, with the alternative target of low disease activity. Follow-up examinations at regular intervals that depend on the patient's status should safeguard the evolution of disease activity towards the targeted goal. Additional recommendations relate to extra-articular and extramusculoskeletal aspects and other important factors, such as comorbidity. While the level of evidence was generally quite low, the mean strength of recommendation was 9-10 (10: maximum agreement) for all recommendations. A research agenda was formulated., Conclusions: The task force defined the treatment target as remission or, alternatively, low disease activity, being aware that the evidence base is not strong and needs to be expanded by future research. These recommendations can inform the various stakeholders about expert opinion that aims for reaching optimal outcomes of SpA.