What changed recently

The 2026 revision of the 2019 adult guideline adds JAK inhibitors as a recommended option (a class absent from the previous version), keeps TNF and IL-17 inhibitors as the preferred first biologics, and advises against IL-23 inhibitors. It also broadens scope with new guidance on nociplastic pain, imaging strategy, bone health and comorbidities, and is accompanied by a first-ever companion guideline for juvenile axial spondyloarthritis.

The task force consolidated the guidance from 11 recommendations down to 9 by merging and deleting items, while keeping methotrexate plus short-term glucocorticoids as the first step and adding a biologic DMARD after 3-6 months of inadequate response. Safety framing was sharpened, with JAK inhibitors requiring explicit assessment of cardiovascular and malignancy risk before use.

The update added a concrete glucocorticoid tapering target of about 5 mg prednisolone equivalent daily by four to five months, and incorporated avacopan as a steroid-sparing strategy in granulomatosis with polyangiitis and microscopic polyangiitis. Rituximab was recommended for remission maintenance in GPA/MPA, and mepolizumab was added for relapsing or refractory eosinophilic GPA.

The acceptable maintenance prednisone ceiling was lowered from 7.5 mg/day to 5 mg/day, and the guidance now pushes earlier addition of immunosuppressants or a biologic for anyone not responding to hydroxychloroquine or unable to taper below that steroid dose. Anifrolumab was added alongside belimumab as an option, and combination regimens with belimumab or voclosporin were endorsed for lupus nephritis; the recommendations were condensed to 13.

Of the 15 recommendations, eight were carried over unchanged and three had wording changes, while the biologic/targeted-synthetic DMARD indication was revised to require an ASDAS of at least 2.1 after failure of two NSAIDs. Two entirely new recommendations were added: one on choosing drugs according to extra-musculoskeletal manifestations such as uveitis, inflammatory bowel disease and psoriasis, and one on re-checking the diagnosis and comorbidities when treatment fails.

The second edition revised more than 80% of the previous recommendations and widened the covered population from age 65 and older down to 55 and older. It dropped the earlier reservation about the posterior surgical approach for femoral neck fracture, newly favours cemented femoral stems for displaced femoral neck fractures and cephalomedullary devices for unstable intertrochanteric fractures, backs tranexamic acid to cut blood loss, and extends interdisciplinary care from dementia patients to all hip fracture patients.

The 2021 guideline reversed the earlier acceptance of low-dose prednisone as bridging therapy, advising against it because patients frequently stay on steroids far longer than intended, and it reaffirmed methotrexate as the anchor drug while conditionally preferring hydroxychloroquine or sulfasalazine for low disease activity. It also added new topics absent from 2015, including methotrexate use in pulmonary disease and fatty liver disease, and treatment alongside nontuberculous mycobacterial lung infection.

Treat-to-target dosing of urate-lowering therapy against serial serum urate measurements, targeting under 6 mg/dL, was upgraded to a strong recommendation on the strength of trials published since 2012. Allopurinol became the explicitly preferred first-line urate-lowering drug for everyone including patients with chronic kidney disease, partly on cost and febuxostat cardiovascular safety concerns, with HLA-B*5801 screening advised first in higher-risk ancestry groups.

The guideline abandoned the stepwise treatment pyramid of 2012 in favour of combining modalities throughout the disease course, and promoted self-efficacy programmes, tai chi, topical and oral NSAIDs and intra-articular steroids from conditional to strong recommendations. Balance exercise for knee and hip OA and duloxetine for knee OA were newly added, while transcutaneous electrical nerve stimulation is now strongly recommended against on evidence of no benefit.

The update restructured the guidance into five overarching principles and ten recommendations and made topical NSAIDs the preferred topical agent and the pharmacological first choice ahead of oral drugs. It also took clearer negative positions than the 2007 version, discouraging conventional and biological DMARDs in hand osteoarthritis and advising against routine intra-articular glucocorticoid injection except in limited circumstances.

The 2017 guideline replaced the 2007 drug-first approach with non-pharmacological treatment as the first-line option for acute, subacute and chronic low back pain. Acetaminophen, endorsed in 2007, was dropped after a placebo-controlled trial showed no pain benefit, leaving NSAIDs as the first drug choice and tramadol or duloxetine as second-line for chronic pain.

The update moved urate-lowering therapy much earlier, advising it be considered from the first presentation of gout rather than after repeated flares, and set explicit serum urate targets of under 6 mg/dL, or under 5 mg/dL in severe disease. It also brought in agents unavailable in 2006, naming febuxostat as an alternative when allopurinol fails to reach target, interleukin-1 blockade for frequent flares with contraindications to standard drugs, and pegloticase for refractory gout.