Incidence, baseline-associated factors and burden of difficult-to-manage axial spondyloarthritis: a 10-year analysis of the DESIR cohort
In brief
About 7% of early axial spondyloarthritis patients become difficult-to-manage
In the 10-year DESIR cohort, 6.8% of patients who started a biologic developed difficult-to-manage disease, rising to 14% under a broader definition. Women and those with higher baseline disease activity were more likely to progress, and affected patients faced more fibromyalgia, medical visits and opioid use, underscoring a lasting socioeconomic burden.
- Journal
- RMD open (Q1)
- Published
- 7 September 2026
- Study design
- Prospective / inception cohort
- Evidence level
- Level 2, Moderate (CEBM 2b)
- Authors
- Olivier Fakih, Anna Moltó, Frank Verhoeven, Clément Prati, Daniel Wendling
- PMID
- 42705859
- DOI
- 10.1136/rmdopen-2026-007094
Why clinicians should know about it
- Picked for Rheumatology (top studies of the week, 13 September 2026): Incidence and burden of difficult-to-manage axial SpA
Abstract
OBJECTIVE: To determine the cumulative incidence of difficult-to-manage axial spondyloarthritis (D2M-axSpA) and treatment-refractory axSpA (TR-axSpA) in a recent-onset axSpA inception cohort, identify baseline factors and characterise long-term outcomes. METHODS: Patients from the French prospective DESIR (DEvenir des Spondyloarthrites Indifférenciées Récentes) cohort fulfilling the Assessment of Spondyloarthritis International Society (ASAS) 2009 criteria for axSpA and exposed to ≥1 biologic disease-modifying antirheumatic drug (bDMARD) were included. Patients with D2M-axSpA and TR-axSpA were classified according to both the ASAS definition and an extended definition adapted to historical treatment availability (failure of ≥3 b/targeted synthetic DMARDs regardless of mechanism of action). Cox proportional hazards models were used to identify baseline factors associated with D2M-axSpA. Clinical, imaging and socio-economic outcomes were analysed over up to 10 years of follow-up. RESULTS: Among 177 patients exposed to ≥1 bDMARD, the cumulative incidence of D2M-axSpA was 6.8% (95% CI 2.4 to 11.0) and 14.4% (95% CI 8.3 to 20.2) using the ASAS and extended definitions, respectively, while TR-axSpA remained rare (0.7% and 3.7%, respectively). Female sex and higher baseline disease activity were associated with the development of D2M-axSpA (extended definition). During follow-up, patients with D2M-axSpA according to the extended definition had a higher prevalence of fibromyalgia (60% vs 22.9%), greater healthcare resource utilisation (cumulative number of medical visits 110 vs 60) and opioid use (100% vs 72%). CONCLUSION: In this recent-onset axSpA inception cohort with long-term follow-up, D2M-axSpA was rare, rarely associated with true treatment refractoriness or structural progression and was accompanied by a persistent disease burden carrying a substantial socio-economic impact, highlighting the need for a broader, patient-centred approach to its management. TRIAL REGISTRATION NUMBER: NCT01648907.
Abstract as published, via PubMed.
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