{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,20]],"date-time":"2026-09-20T03:34:20Z","timestamp":1789875260554,"version":"4.0.1"},"reference-count":21,"publisher":"Wiley","issue":"2","license":[{"start":{"date-parts":[[2026,1,28]],"date-time":"2026-01-28T00:00:00Z","timestamp":1769558400000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/onlinelibrary.wiley.com\/termsAndConditions#vor"},{"start":{"date-parts":[[2026,1,28]],"date-time":"2026-01-28T00:00:00Z","timestamp":1769558400000},"content-version":"tdm","delay-in-days":0,"URL":"http:\/\/doi.wiley.com\/10.1002\/tdm_license_1.1"}],"content-domain":{"domain":["onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["Int J of Rheum Dis"],"published-print":{"date-parts":[[2026,2]]},"abstract":"<jats:title>ABSTRACT<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Objective<\/jats:title>\n                    <jats:p>To evaluate the clinical characteristics, disease burden, and treatment patterns of axial spondyloarthritis (axSpA) using the recently proposed Assessment of Spondyloarthritis International Society (ASAS) definition of difficult\u2010to\u2010manage axSpA (D2M\u2010axSpA).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>A total of 383 patients with axSpA were enrolled. This multicenter cross\u2010sectional study was conducted in three tertiary care centers, enrolling consecutive axSpA patients from outpatient clinics. Patients were classified as D2M\u2010axSpA based on prior use of biologic or targeted synthetic disease\u2010modifying antirheumatic drugs (b\/tsDMARDs) and persistent disease activity based on the ASAS definition. Logistic regression analysis identified factors associated with D2M\u2010axSpA.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      Among patients, 11.2% met the D2M\u2010axSpA criteria. The cohort was 58.7% male, with a mean age of 43.5\u2009\u00b1\u200910.5\u2009years. Radiographic axSpA was present in 70.8%, and 69.2% of patients had received biological therapy. D2M\u2010axSpA patients exhibited higher inflammatory markers (ESR, CRP), increased disease activity (BASDAI, ASDAS\u2010CRP), and greater functional impairment (BASFI, ASQoL). Peripheral arthritis (\n                      <jats:italic>p<\/jats:italic>\n                      \u2009=\u20090.001), enthesitis (\n                      <jats:italic>p<\/jats:italic>\n                      \u2009=\u20090.031), smoking history (\n                      <jats:italic>p<\/jats:italic>\n                      \u2009=\u20090.037), and comorbidities (\n                      <jats:italic>p<\/jats:italic>\n                      \u2009=\u20090.020) were significantly more frequent in D2M\u2010axSpA. Among D2M\u2010axSpA patients, 22\/383 (5.7%) fulfilled the treatment\u2010refractory criteria. Radiographic findings revealed higher rates of sacroiliac ankylosis, lumbar syndesmophytes, symphysitis, and ischial enthesitis, as well as mSASSS scores. Logistic regression identified anterior uveitis (OR: 4.474,\n                      <jats:italic>p<\/jats:italic>\n                      \u2009=\u20090.007), peripheral arthritis (OR: 2.684,\n                      <jats:italic>p<\/jats:italic>\n                      \u2009=\u20090.021), and comorbidities (OR: 2.878,\n                      <jats:italic>p<\/jats:italic>\n                      \u2009=\u20090.013) as independently associated factors.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>Findings highlight the clinical and radiographic burden of D2M\u2010axSpA and emphasize the need for optimized treatment strategies, particularly in patients with comorbidities, a history of anterior uveitis or peripheral arthritis, and those with a smoking history.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1111\/1756-185x.70558","type":"journal-article","created":{"date-parts":[[2026,1,28]],"date-time":"2026-01-28T09:58:52Z","timestamp":1769594332000},"update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":3,"title":["Clinical and Radiographic Factors Associated With Difficult\u2010to\u2010Manage Axial Spondyloarthritis: A Multicenter Study"],"prefix":"10.1111","volume":"29","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-1757-0598","authenticated-orcid":false,"given":"Haluk","family":"Cinakli","sequence":"first","affiliation":[{"name":"Rheumatology Department K\u0131rklareli Training and Research Hospital  K\u0131rklareli Turkey"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4690-610X","authenticated-orcid":false,"given":"Mete","family":"Kara","sequence":"additional","affiliation":[{"name":"Rheumatology Department, Izmir City Hospital  Izmir Turkey"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1908-8439","authenticated-orcid":false,"given":"G\u00fclay","family":"Alp","sequence":"additional","affiliation":[{"name":"Division of Rheumatology, Department of Internal Medicine U\u015fak University School of Medicine  U\u015fak 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Development and Validation of a Radiographic Grading System for the Hip in Ankylosing Spondylitis: The Bath Ankylosing Spondylitis Radiology Hip Index \u201dDecember 16 2023 https:\/\/pubmed.ncbi.nlm.nih.gov\/11128678\/."},{"key":"e_1_2_10_18_1","doi-asserted-by":"publisher","DOI":"10.1093\/RHEUMATOLOGY\/KEY128"},{"key":"e_1_2_10_19_1","unstructured":"\u201cDifficult\u2010to\u2010Treat Axial Spondyloarthritis is Associated With Psoriasis Peripheral Involvement and Comorbidities: Results of an Observational Nationwide Study \u201dFebruary 23 2025 https:\/\/pubmed.ncbi.nlm.nih.gov\/37996127\/."},{"key":"e_1_2_10_20_1","doi-asserted-by":"publisher","DOI":"10.55563\/CLINEXPRHEUMATOL\/NYU9ER"},{"key":"e_1_2_10_21_1","doi-asserted-by":"publisher","DOI":"10.1136\/ANNRHEUMDIS\u20102024\u2010EULAR.6232"},{"key":"e_1_2_10_22_1","doi-asserted-by":"publisher","DOI":"10.1136\/ANNRHEUMDIS\u20102011\u2010200180"}],"container-title":["International Journal of Rheumatic 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