ArticleTherapeutic advances in musculoskeletal disease2026
Prevalence and clinical factors associated with difficult-to-manage axial spondyloarthritis: a multicentre Italian cohort study with meta-analysis.
Article in Therapeutic advances in musculoskeletal disease, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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Abstract
Background: The concept of difficult-to-manage axial spondyloarthritis (D2M-axSpA) has recently been introduced to describe patients with a persistent disease burden despite appropriate treatment. However, its real-world prevalence and associated clinical features remain insufficiently characterised. Objective: To estimate the prevalence of D2M and treatment-refractory (TR) axSpA in routine clinical practice, identify factors associated with D2M, and assess the consistency of selected D2M-associated features across different cohorts. Design and methods: A cross-sectional study was conducted in 252 patients with axSpA from two Italian tertiary centres. The 2024 Assessment of Spondyloarthritis International Society consensus-based definition was applied to identify D2M and TR axSpA. Clinical, laboratory and imaging characteristics were compared between D2M and non-D2M patients. Factors independently associated with D2M were evaluated using multivariable logistic regression. To explore consistency across populations, an exploratory meta-analysis was performed using harmonised data from the published Argentinian Reuma-Check cohort. Results: Among 252 patients with axSpA, 16 (6.3%) fulfilled the definition of D2M, and 8 (3.2%) met criteria for TR axSpA. Patients with D2M exhibited higher disease activity (Axial Spondyloarthritis Disease Activity Score 2.50 ± 0.62 vs 1.24 ± 0.65; Conclusion: D2M axSpA was identified in approximately 6.3% of patients, while 3.2% fulfilled criteria for TR axSpA. Fibromyalgia, NSAID use and uveitis were independently associated with the D2M phenotype, whereas meta-analytic evidence highlighted additional associations with psoriasis, smoking and structural damage. These findings support the multifactorial nature of D2M axSpA, in which both inflammatory and non-inflammatory mechanisms contribute to disease complexity.
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