Chinese recommendations for the diagnosis and management of non‑radiographic axial spondyloarthritis（2026）上海市第六...

Journal：Autoimmunity Reviews, 2026, 25(5):104039；Online ahead‑of‑print March 2026 Task force：Chinese Rheumatology Association；53 rheumatologists +7 musculoskeletal radiologists；Systematic review + Delphi consensus；37 clinical questions；6 general principles +17 recommendations Core mission：address global over‑diagnosis and mis‑diagnosis of nr‑axSpA；emphasize classification criteria ≠ diagnostic criteria；establish stratified diagnosis, treat‑to‑target, radiographic‑progression‑risk‑stratified management framework

Ⅰ. Six General Principles

1. Non‑radiographic axial spondyloarthritis (nr‑axSpA) belongs to the spectrum of axial spondyloarthritis (axSpA), defined by inflammatory back pain ≥3 months, onset age＜45 years, no definite sacroiliac structural damage on conventional radiograph, with objective inflammatory evidence (SI‑joint MRI bone‑marrow oedema/BME, or typical SpA phenotype plus HLA‑B27 positivity). It is not equivalent to “early ankylosing spondylitis”.
2. ASAS classification criteria are designed for clinical trial enrolment, cannot substitute clinical diagnosis. Diagnosis must integrate clinical phenotype, laboratory, imaging and exclusion of mimicking disorders.
3. Therapeutic goal: achieve and sustain low disease activity or remission; relieve pain/stiffness; preserve spinal function; reduce risk of progression to radiographic axSpA (r‑axSpA).
4. Non‑pharmacological interventions (exercise, patient education, physiotherapy, smoking cessation) are fundamental, should be implemented for all patients throughout disease course.
5. Management should stratify patients according to disease activity, imaging inflammatory burden, progression‑risk factors and comorbidities.
6. Multidisciplinary collaboration (rheumatology, musculoskeletal radiology, rehabilitation, orthopaedics) improves diagnostic accuracy and long‑term outcome.

Ⅱ. Diagnosis & differential‑diagnosis recommendations (Rec 1‑7)

1. For patients with chronic back pain ≥3 months, onset＜45 years: screen for inflammatory back pain, SpA extra‑axial manifestations (enthesitis, dactylitis, psoriasis, IBD, uveitis), family history of SpA; test HLA‑B27, CRP/ESR.
2. Pelvic X‑ray is mandatory baseline examination to exclude definite radiographic sacroiliitis.
3. Sacral‑iliac joint MRI is the key test to detect active inflammation for nr‑axSpA. Strict MRI reading standards: only bone‑marrow oedema located in subchondral bone of sacroiliac joints counts as positive inflammatory lesion. Isolated joint‑fluid, fat metaplasia, sclerosis without BME cannot confirm active sacroiliitis.
4. Warn against over‑interpretation of MRI signal: many non‑SpA conditions can produce SI‑joint BME (mechanical stress, postpartum changes, osteoarthritis, infection).
5. HLA‑B27 alone cannot establish nr‑axSpA diagnosis; B27‑negative nr‑axSpA exists, usually with lower progression risk.
6. Differential diagnosis priority: mechanical low‑back pain, degenerative spine disease, fibromyalgia, diffuse idiopathic skeletal hyperostosis (DISH), infection, SAPHO, metabolic bone disease.
7. If clinical suspicion is high but MRI remains equivocal: follow‑up re‑evaluation in 3‑6 months instead of immediate labelling as nr‑axSpA.

Ⅲ. Prognostic risk‑stratification (Rec 8‑9)

8. High‑risk factors for progression towards radiographic axSpA: persistently elevated CRP, marked SI‑joint multi‑site BME on MRI, positive HLA‑B27, young onset, smoking, enthesitis. Patients with ≥2 high‑risk factors need closer monitoring.
9. Baseline and follow‑up outcome assessment instruments: BASDAI, ASDAS‑CRP for disease activity; BASFI for function; periodic pelvic radiograph for structural progression.

Ⅳ. Non‑pharmacological therapy (Rec10‑11)

10. All nr‑axSpA patients: regular spinal‑targeted physical exercise; smoking cessation is strongly recommended (smoking aggravates inflammation and increases radiographic progression risk).
11. Physiotherapy, patient education and psychological support are essential; avoid long‑term bed rest.

Ⅴ. Pharmacological management (Rec12‑16)

12. NSAIDs as first‑line drug for symptomatic control. Full‑dose NSAIDs trial for 2‑4 weeks; evaluate response. If well‑tolerated partial response, intermittent‑on‑demand use is acceptable.

    csDMARDs (methotrexate, sulfasalazine): no proven efficacy for pure axial involvement, not recommended for isolated nr‑axSpA.

13. Persistently active nr‑axSpA (ASDAS‑CRP ≥2.1) despite adequate NSAIDs: initiate bDMARDs (TNF‑α inhibitors or IL‑17 inhibitors).
    • High‑progression‑risk patients give priority to earlier bDMARD initiation.
    • For patients with concomitant psoriasis / IBD, select biologic matching extra‑articular manifestations.
14. tsDMARD (JAK‑inhibitors): alternative for patients failing or intolerant to bDMARDs; pre‑treatment screening for cardiovascular and thromboembolic risk.
15. Systemic glucocorticoids are not recommended for routine long‑term management of nr‑axSpA. Local peri‑articular / entheseal injection can be used for localized lesions.
16. Tapering strategy: after sustained clinical remission (≥6 months), gradual dose reduction of biologic agents can be considered; close monitoring for flare. Rapid complete discontinuation associates with high relapse risk.

Ⅵ. Follow‑up (Rec17)

17. Active phase: follow‑up every 8‑12 weeks using ASDAS‑CRP/BASDAI; stable remission: every 6‑12 months. Pelvic radiograph is recommended every 2‑3 years in high‑risk subgroup to detect new structural sacroiliitis.

Key highlights of this Chinese recommendation

1. Explicit warning: ASAS classification criteria are for research enrolment, not clinical diagnostic criteria, to fight worldwide nr‑axSpA overdiagnosis.
2. Detailed MRI interpretation pitfalls: isolated joint effusion, fat metaplasia cannot be regarded as active sacroiliitis.
3. Prognostic risk‑stratification guiding intensity of monitoring and treatment decisions.
4. Confirm csDMARDs have no benefit for pure axial disease.
5. Tapering rather than abrupt withdrawal of biologics in sustained remission.

Reference

Dai SM, Xu HJ, Zhao Y, et al. Chinese recommendations for the diagnosis and management of non‑radiographic axial spondyloarthritis. Autoimmun Rev. 2026;25(5):104039. doi:10.1016/j.autrev.2026.104039上海市第六...