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TOPLINE:

Among patients with axial spondyloarthritis (axSpA), 9.1% fulfilled the criteria for difficult-to-manage (D2M) disease, with 2.2% meeting the criteria for treatment-refractory disease. Higher spinal pain scores and fibromyalgia were independently linked to D2M axSpA.

METHODOLOGY:

• Researchers performed a cross-sectional analysis of prospectively collected data to determine the prevalence of D2M axSpA and identify associated factors in 536 patients with axSpA (median age, 48 years; 66% male) who attended follow-up visits between May 2024 and May 2025 at an institute in Toronto, Ontario, Canada.
• The Assessment of SpondyloArthritis International Society (ASAS) definitions for D2M and treatment-refractory disease were applied, with D2M defined as treatment failure with at least two biologic/targeted synthetic disease-modifying antirheumatic drugs (b/tsDMARDs) with different mechanisms, inadequately controlled signs or symptoms, and a rheumatologist’s or patient’s perception that the situation was problematic.
• Treatment-refractory axSpA was defined as having D2M disease with treatment failure, an Axial Spondyloarthritis Disease Activity Score (ASDAS) ≥ 2.1, and objective signs of uncontrolled inflammation such as C-reactive protein levels ≥ 5 mg/L or inflammation on MRI.
• Primary nonresponse was characterized as a lack of a clinically meaningful response to a b/tsDMARD within 3-6 months of initiation, and secondary nonresponse indicated a loss of response beyond 6 months after starting treatment.

TAKEAWAY:

• Overall, 9.1% met the ASAS D2M definition and 2.2% were classified as having treatment-refractory axSpA.
• Patients with D2M axSpA had higher disease activity than those with non-D2M axSpA (median ASDAS, 2.8 vs 1.6). Similarly, patients with treatment-refractory axSpA had greater disease burden, with a higher median ASDAS (3.5 vs 2.7).
• Patients with D2M axSpA vs those with non-D2M axSpA had a higher prevalence of a history of peripheral arthritis (36.7% vs 20.8%), current enthesitis (14.9% vs 7.2%), and recent psoriasis (24.5% vs 16.4%) but a lower prevalence of recent uveitis (0% vs 6.4%).
• Higher total spinal pain scores (adjusted odds ratio [aOR], 1.48; 95% CI, 1.29-1.70) and fibromyalgia (aOR, 3.09; 95% CI, 1.33-7.15) were independently associated with D2M axSpA.

IN PRACTICE:

“[The study] findings support the clinical relevance of the D2M and TR [treatment-refractory] constructs, underscore the heterogeneity of pathways leading to perceived nonresponse, and reinforce the need for integrated, phenotype-informed care,” the authors wrote.

SOURCE:

The study was led by Patricia Remalante-Rayco, MD, MSc, Schroeder Arthritis Institute, Toronto Western Hospital, Spondylitis Program, University Health Network, Toronto. It was published online on April 27, 2026, in Arthritis & Rheumatology.

LIMITATIONS:

The study’s cross-sectional design and the small number of D2M and treatment-refractory events made it hard to test interactions or identify factors. Reliance on patients’ self-assessments to gauge their perception of disease might have led to an overestimation of D2M prevalence.

DISCLOSURES:

No specific funding source was reported. Some authors reported receiving grants, consulting fees, and/or honoraria or having other ties with various companies including UCB, Novartis, and AbbVie.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.