Korean College of Rheumatology treatment recommendations for patients with axial spondyloarthritis: 2026 update.

We aimed to develop updated evidence-based recommendations for the management of adult patients with axial spondyloarthritis (axSpA) in Korea. The Korean College of Rheumatology convened a multidisciplinary panel to update the 2023 axSpA guideline. Twenty key clinical questions were formulated using the PICO framework. Systematic literature searches were conducted in PubMed, Embase, and the Cochrane Library for studies published between February 2021 and December 2024. Evidence was appraised using the GRADE methodology, and recommendations were finalized through a modified Delphi consensus process. Twenty recommendations were developed covering disease activity monitoring, non-pharmacological interventions, pharmacological treatment, treatment sequencing, tapering strategies, comorbidity management, surgical interventions, and safety monitoring. Key recommendations include implementation of a treat-to-target strategy, use of Axial Spondyloarthritis Disease Activity Score for disease assessment, smoking cessation and exercise, nonsteroidal anti-inflammatory drugs (NSAIDs) as first-line therapy, and the use of tumor necrosis factor inhibitors, interleukin-17 inhibitors, or Janus kinase inhibitors in patients with active disease refractory to NSAIDs. Recommendations were also provided for treatment selection according to extra-musculoskeletal manifestations and for monitoring treatment-related adverse events. These updated recommendations provide evidence-based guidance for the comprehensive management of axSpA in Korea and aim to improve clinical outcomes, quality of life, and standardization of care.