Points to Consider in D2M/Treatment Refractory axSpA Save

Despite an increasing number of highly effective therapies for axial spondyloarthritis (axSpA), a proportion of patients continue to experience difficult-to-manage (D2M) disease. In response, the Assessment of SpondyloArthritis international Society (ASAS) recently developed consensus definitions for both D2M and treatment-refractory (TR) axSpA. Building on this foundation, ASAS also formulated 'Points to Consider' for the management of D2M/TR axSpA that Dr. Dennis Poddubnyy presented on behalf of the group during day 4 abstract sessions at ACR (abstract 2944)

These consensus statements consist of four (4) overarching principles and 10 Points to Consider. The overarching principles define D2M axSpA as factors related or unrelated to the underlying disease while TR axSpA refers to persistent inflammatory activity despite appropriate therapy. The group also emphasized the critical aspect of patient information, shared decision making between the patient and the healthcare team as well as the adoption of a holistic, comprehensive and multidisciplinary management approach. 

A total of 10 Points to Consider were developed by ASAS and discussed by Dr. Poddubnyy:

1. Misdiagnosis or mimics - The occurrence of misdiagnosis or coexistence of another condition should be carefully assessed in patients who fulfill the diagnosis of axSpA
2. Diagnostic re-evaluation – The rheumatologist should perform a comprehensive re-evaluation of axSpA, including careful history taking, physical examination and critical review of prior investigations where appropriate. Imaging may be repeated or extended. For example, extension of imaging to the spine may be done if imaging of the SI joints are deemed equivocal or inadequate to generate a proper assessment.
3. Objective inflammatory activity – Patients with a confirmed diagnosis of axSpA should undergo an objective evaluation to confirm the presence of inflammation with the use of appropriate imaging modalities such as MRI, ultrasound, or acute-phase reactants if clinically warranted.
4. Treatment adherence – Dr. Poddybnyy reminds clinicians to ensure that patients are taking their medications before giving the label of D2M axSpA. Verify and optimize adherence to non-pharmacologic and pharmacological interventions taking into account potential contextuial, socio-economic and health factors.
5. Extra-musculoskeletal manifestations – Consider the presence of ongoing inflammatory activity secondary to extra-musculoskeletal manifestations such as anterior uveitis, inflammatory bowel disease and psoriasis. These conditions should be evaluated and managed in coordination with appropriate specialists.
6. Comorbidities mimicking symptoms of axSpA – comorbidities that may mimic axSpA symptoms or interfere with assessment of disease activity should be identified, discussed with the patient and addressed thoroughly. 

The ASAS panel provided a list of potential mimics and factors that may interfere with proper assessment. An example that Dr. Poddybnyy highlighted is nociplastic pain as a potential mimicker or causative factor in an axSpA patient. Other factors include central sensitization, mechanical or degenerative disorders of the spine and sacroiliac joints, hip disorders, fractures, crystal deposition disease and metabolic bone disorders, infection, malignancy, mental health and psychosocial factors, sleep, metabolic disorders and deconditioning. 

7. Structural damage progression – this aspect should be interpreted in the context of current and prior control of inflammatory activity and related modifiable risk factors.
8. Non-pharmacological care – non-pharmacological interventions catered to the patient’s needs should be integrated in the management of D2M axSpA.
9. Education and self-management – These two elements should be offered in order to enhance patient’s understanding of the disease, provide effective management of symptoms, ensure treatment adherence and empower engagement in shared decision making.
10. Individualized treatment strategies for treatment-refractory (TR) axSpA – alternative treatment strategies such as switching, dose optimization and dual combination therapies with targeted DMARDs should be individualized.

The ASAS Points to Consider aim to provide a structured framework in the reassessment and individualized management of patients with D2M axSpA. Conversely, it is the rheumatologist’s role to ensure that relevant factors are considered, confounding elements are ruled out before appropriate treatment is provided to patients with D2M/TR axSpA.