{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,17]],"date-time":"2026-09-17T21:11:17Z","timestamp":1789679477479,"version":"4.0.1"},"reference-count":49,"publisher":"BMJ","issue":"1","license":[{"start":{"date-parts":[[2024,1,8]],"date-time":"2024-01-08T00:00:00Z","timestamp":1704672000000},"content-version":"unspecified","delay-in-days":7,"URL":"http:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["RMD Open"],"accepted":{"date-parts":[[2023,12,6]]},"published-print":{"date-parts":[[2024,1]]},"abstract":"<jats:sec>\n                  <jats:title>Background<\/jats:title>\n                  <jats:p>Psoriatic arthritis (PsA) is a multifaceted condition with a broad spectrum of manifestations and a range of associated comorbidities. A notable segment of patients with PsA remains resistant to even advanced therapeutic interventions. This resistance stems from myriad causes, including inflammatory and non-inflammatory factors.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Objectives<\/jats:title>\n                  <jats:p>To collate and critically assess the various definitions and criteria of difficult-to-treat (D2T PsA present in the literature.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Methods<\/jats:title>\n                  <jats:p>Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines, we conducted a scoping review in July 2023, searching PubMed, American College of Rheumatology Convergence 2022, European Alliance of Associations for Rheumatology Congress 2023, Google Scholar and cited articles. Selection was made by two independent authors using Rayyan software, and conflicts were adjudicated by a third author. Eligibility criteria for PubMed focused on all article designs that were written in English, with full-text available, from the past decade, excluding only those not defining D2T PsA or targeting other populations.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Results<\/jats:title>\n                  <jats:p>From the 565 references sourced, 15 studies were analysed, revealing considerable variations in defining both \u2018active disease\u2019 and \u2018resistant PsA\u2019, which was most often termed \u2018D2T\u2019 PsA.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Conclusion<\/jats:title>\n                  <jats:p>The definitions and criteria for D2T PsA and for \u2018active disease\u2019 are notably heterogeneous, with considerable variation across sources. The ongoing Group for Research and Assessment of Psoriasis and Psoriatic Arthritis initiative stands to bridge these definitional gaps and aims to provide guidance for clinicians and illuminate a path for pharmaceuticals and regulatory agencies to follow.<\/jats:p>\n               <\/jats:sec>","DOI":"10.1136\/rmdopen-2023-003809","type":"journal-article","created":{"date-parts":[[2024,1,10]],"date-time":"2024-01-10T00:59:47Z","timestamp":1704848387000},"page":"e003809","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":76,"title":["Difficult-to-treat psoriatic arthritis (D2T PsA): a scoping literature review informing a GRAPPA research project"],"prefix":"10.1136","volume":"10","author":[{"given":"Shikha","family":"Singla","sequence":"first","affiliation":[{"name":"Department of Rheumatology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6782-8924","authenticated-orcid":false,"given":"Andre","family":"Ribeiro","sequence":"additional","affiliation":[{"name":"Rheumatology, Hospital de Cl\u00ednicas de Porto Alegre, Porto Alegre, Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4600-9484","authenticated-orcid":false,"given":"Murat","family":"Torgutalp","sequence":"additional","affiliation":[{"name":"Corporate Member of Freie Universit\u00e4t Berlin and Humboldt-Universit\u00e4t zu Berlin, Department of Gastroenterology, Infectious Diseases and Rheumatology (including Nutrition Medicine), Charite Universitatsmedizin Berlin, Berlin, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6620-0457","authenticated-orcid":false,"given":"Philip J","family":"Mease","sequence":"additional","affiliation":[{"name":"School of Medicine, Swedish Medical Center and University of Washington, Seattle, Washington, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4306-033X","authenticated-orcid":false,"given":"Fabian","family":"Proft","sequence":"additional","affiliation":[{"name":"Department of Gastroenterology, Infectiology and Rheumatology (including Nutrition Medicine), Charite Universitatsmedizin Berlin, Berlin, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2024,1,8]]},"reference":[{"key":"2025090313063207000_10.1.e003809.1","doi-asserted-by":"crossref","DOI":"10.1007\/s11926-019-0876-z","article-title":"Strategies to improve outcomes in psoriatic arthritis","volume":"21","author":"Ritchlin","year":"2019","journal-title":"Curr Rheumatol Rep"},{"key":"2025090313063207000_10.1.e003809.2","doi-asserted-by":"crossref","DOI":"10.1038\/s41584-022-00861-w","article-title":"Author correction: group for research and assessment of psoriasis and psoriatic arthritis (GRAPPA): updated treatment recommendations for psoriatic arthritis 2021","volume":"18","author":"Coates","year":"2022","journal-title":"Nat Rev Rheumatol"},{"key":"2025090313063207000_10.1.e003809.3","doi-asserted-by":"crossref","first-page":"304","DOI":"10.1097\/BOR.0000000000000388","article-title":"Fibromyalgia, a missed comorbidity in spondyloarthritis: prevalence and impact on assessment and treatment","volume":"29","author":"Mease","year":"2017","journal-title":"Curr Opin Rheumatol"},{"key":"2025090313063207000_10.1.e003809.4","doi-asserted-by":"crossref","first-page":"351","DOI":"10.1016\/j.semarthrit.2017.05.010","article-title":"The psychosocial burden of psoriatic arthritis","volume":"47","author":"Husni","year":"2017","journal-title":"Semin Arthritis Rheum"},{"key":"2025090313063207000_10.1.e003809.5","doi-asserted-by":"crossref","DOI":"10.1186\/s12955-020-01422-z","article-title":"Results of a global, patient-based survey assessing the impact of psoriatic arthritis discussed in the context of the psoriatic arthritis impact of disease (PsAID) questionnaire","volume":"18","author":"Coates","year":"2020","journal-title":"Health Qual Life Outcomes"},{"key":"2025090313063207000_10.1.e003809.6","doi-asserted-by":"crossref","first-page":"826","DOI":"10.1016\/j.clinthera.2023.05.010","article-title":"Pharmacologic treatment strategies in psoriatic arthritis","volume":"45","author":"Ayan","year":"2023","journal-title":"Clin Ther"},{"key":"2025090313063207000_10.1.e003809.7","doi-asserted-by":"publisher","DOI":"10.3899\/jrheum.170449"},{"key":"2025090313063207000_10.1.e003809.8","doi-asserted-by":"crossref","first-page":"e200","DOI":"10.1016\/S2665-9913(23)00034-6","article-title":"Association between biological immunotherapy for psoriasis and time to incident inflammatory arthritis: a retrospective cohort study","volume":"5","author":"Singla","year":"2023","journal-title":"The Lancet Rheumatology"},{"key":"2025090313063207000_10.1.e003809.9","doi-asserted-by":"crossref","DOI":"10.1136\/rmdopen-2016-000415","article-title":"Prediction and benefits of minimal disease activity in patients with psoriatic arthritis and active skin disease in the ADEPT trial","volume":"3","author":"Mease","year":"2017","journal-title":"RMD Open"},{"key":"2025090313063207000_10.1.e003809.10","doi-asserted-by":"publisher","DOI":"10.1016\/S0140-6736(18)30830-4"},{"key":"2025090313063207000_10.1.e003809.11","doi-asserted-by":"crossref","first-page":"1119","DOI":"10.1007\/s40744-023-00574-w","article-title":"Difficult to treat and refractory to treatment in psoriatic arthritis","volume":"10","author":"Lubrano","year":"2023","journal-title":"Rheumatol Ther"},{"key":"2025090313063207000_10.1.e003809.12","doi-asserted-by":"crossref","first-page":"860","DOI":"10.1016\/j.clinthera.2023.04.005","article-title":"Challenges in the management of psoriatic arthritis in Latin America: a systematic review","volume":"45","author":"Ribeiro","year":"2023","journal-title":"Clin Ther"},{"key":"2025090313063207000_10.1.e003809.13","doi-asserted-by":"publisher","DOI":"10.1136\/annrheumdis-2020-217344"},{"key":"2025090313063207000_10.1.e003809.14","unstructured":"ASAS definition of difficult-to-treat axial spondyloarthritis - ASAS. 2022. Available: https:\/\/www.asas-group.org\/asas-definition-of-difficult-to-treat-axial-spondyloarthritis\/ [Accessed 09 Sep 2023]."},{"key":"2025090313063207000_10.1.e003809.15","doi-asserted-by":"publisher","DOI":"10.7326\/M18-0850"},{"key":"2025090313063207000_10.1.e003809.16","doi-asserted-by":"publisher","DOI":"10.1007\/s10067-014-2603-5"},{"key":"2025090313063207000_10.1.e003809.17","doi-asserted-by":"publisher","DOI":"10.1016\/S0140-6736(17)31429-0"},{"key":"2025090313063207000_10.1.e003809.18","doi-asserted-by":"crossref","first-page":"4367","DOI":"10.1093\/rheumatology\/keaa824","article-title":"Improvement from Ixekizumab treatment in patients with psoriatic arthritis who have had an inadequate response to one or two TNF inhibitors","volume":"60","author":"Kirkham","year":"2021","journal-title":"Rheumatology (Oxford)"},{"key":"2025090313063207000_10.1.e003809.19","doi-asserted-by":"crossref","first-page":"38","DOI":"10.1016\/S0140-6736(22)02303-0","article-title":"Bimekizumab in patients with active psoriatic arthritis and previous inadequate response or intolerance to tumour necrosis factor-\u0391 inhibitors: a randomised, double-blind","volume":"401","author":"Merola","year":"2023","journal-title":"Lancet"},{"key":"2025090313063207000_10.1.e003809.20","doi-asserted-by":"crossref","first-page":"1792","DOI":"10.1136\/annrheumdis-2023-eular.4922","article-title":"AB1125\u2005treatment with upadacinitib in refractory psoriatic arthritis. Multicenter study of 101 patients of clinical practice","volume":"82","author":"Gal\u00edndez-Agirregoikoa","year":"2023","journal-title":"Ann Rheum Dis"},{"key":"2025090313063207000_10.1.e003809.21","doi-asserted-by":"publisher","DOI":"10.3899\/jrheum.201204"},{"key":"2025090313063207000_10.1.e003809.22","doi-asserted-by":"crossref","first-page":"155","DOI":"10.1007\/s40268-023-00422-w","article-title":"Single-centre real-world study on drug survival and effectiveness of brodalumab for treatment of psoriasis and psoriatic arthritis","volume":"23","author":"Elgaard","year":"2023","journal-title":"Drugs R D"},{"key":"2025090313063207000_10.1.e003809.23","doi-asserted-by":"crossref","first-page":"1799","DOI":"10.1136\/annrheumdis-2023-eular.3948","article-title":"AB1138\u2005Difficult-to-treat psoriatic arthritis: analysis of a single-center cohort from northern Italy","volume":"82","author":"Cincinelli","year":"2023","journal-title":"Ann Rheum Dis"},{"key":"2025090313063207000_10.1.e003809.24","doi-asserted-by":"crossref","DOI":"10.3389\/fmed.2023.1184028","article-title":"Changes in musculoskeletal disease activity and patient-reported outcomes in patients with psoriatic arthritis treated with Ixekizumab: results from a real-world US cohort","volume":"10","author":"Tillett","year":"2023","journal-title":"Front Med (Lausanne)"},{"key":"2025090313063207000_10.1.e003809.25","doi-asserted-by":"crossref","first-page":"1193","DOI":"10.1007\/s40744-022-00461-w","article-title":"Clinical characteristics of potential \u201cdifficult-to-treat\u201d patients with psoriatic arthritis: a retrospective analysis of a longitudinal cohort","volume":"9","author":"Perrotta","year":"2022","journal-title":"Rheumatol Ther"},{"key":"2025090313063207000_10.1.e003809.26","doi-asserted-by":"crossref","first-page":"2529","DOI":"10.1007\/s10067-023-06627-3","article-title":"Difficult to treat psoriatic arthritis - how should we manage","volume":"42","author":"Kumthekar","year":"2023","journal-title":"Clin Rheumatol"},{"key":"2025090313063207000_10.1.e003809.27","doi-asserted-by":"crossref","first-page":"1121","DOI":"10.1136\/annrheumdis-2023-eular.1333","article-title":"POS1521\u2005characteristics of difficult to treat psoriatic arthritis: a comparative analysis","volume":"82","author":"Philippoteaux","year":"2023","journal-title":"Ann Rheum Dis"},{"key":"2025090313063207000_10.1.e003809.28","doi-asserted-by":"publisher","DOI":"10.1056\/NEJMoa1615977"},{"key":"2025090313063207000_10.1.e003809.29","doi-asserted-by":"crossref","DOI":"10.5041\/RMMJ.10494","article-title":"Dual biologic therapy in patients with rheumatoid arthritis and psoriatic arthritis","volume":"14","author":"Furer","year":"2023","journal-title":"Rambam Maimonides Med J"},{"key":"2025090313063207000_10.1.e003809.30","doi-asserted-by":"crossref","first-page":"1394","DOI":"10.1136\/annrheumdis-2018-213700","article-title":"Overdiagnosis and overtreatment in rheumatology: a little caution is in order","volume":"77","author":"Landew\u00e9","year":"2018","journal-title":"Ann Rheum Dis"},{"key":"2025090313063207000_10.1.e003809.31","doi-asserted-by":"crossref","first-page":"147","DOI":"10.1007\/s11606-022-07707-x","article-title":"Revisiting the time needed to provide adult primary care","volume":"38","author":"Porter","year":"2023","journal-title":"J Gen Intern Med"},{"key":"2025090313063207000_10.1.e003809.32","doi-asserted-by":"crossref","unstructured":"Miedany YE , Kamel N , Abu-Zaid MH , et al . Ab1146 physician adherence to clinical guidelines in rheumatology: can it help providing evidence-based, standardized clinical decisions. Ann Rheum Dis 2023;82:1803:doi:10.1136\/annrheumdis-2023-eular.1090.","DOI":"10.1136\/annrheumdis-2023-eular.1090"},{"key":"2025090313063207000_10.1.e003809.33","doi-asserted-by":"crossref","first-page":"1435","DOI":"10.1002\/acr.24598","article-title":"Health resource utilization and associated health care costs of biologic disease-modifying antirheumatic drugs in German patients with psoriatic arthritis","volume":"74","author":"Sewerin","year":"2022","journal-title":"Arthritis Care Res (Hoboken)"},{"key":"2025090313063207000_10.1.e003809.34","doi-asserted-by":"crossref","DOI":"10.1136\/bmj-2022-072953","article-title":"Guidelines should consider clinicians\u2019 time needed to treat","volume":"380","author":"Johansson","year":"2023","journal-title":"BMJ"},{"key":"2025090313063207000_10.1.e003809.35","doi-asserted-by":"crossref","first-page":"307","DOI":"10.1016\/S2468-1253(22)00427-7","article-title":"Guselkumab plus golimumab combination therapy versus guselkumab or golimumab monotherapy in patients with ulcerative colitis (VEGA): a randomised, double-blind, controlled, phase 2, proof-of-concept trial","volume":"8","author":"Feagan","year":"2023","journal-title":"Lancet Gastroenterol Hepatol"},{"key":"2025090313063207000_10.1.e003809.36","unstructured":"Combined biological or targeted therapy in spondyloarthritis: experience from a multicenter case series in Spain [ACR Meeting Abstracts]. Available: https:\/\/acrabstracts.org\/abstract\/combined-biological-or-targeted-therapy-in-spondyloarthritis-experience-from-a-multicenter-case-series-in-spain\/ [Accessed 03 Sep 2023]."},{"key":"2025090313063207000_10.1.e003809.37","doi-asserted-by":"crossref","first-page":"e225","DOI":"10.1093\/rheumatology\/keaa880","article-title":"Induction of remission in biologic-naive, severe psoriasis and PSA with dual anti-cytokine combination","volume":"60","author":"Haberman","year":"2021","journal-title":"Rheumatology (Oxford)"},{"key":"2025090313063207000_10.1.e003809.38","doi-asserted-by":"crossref","first-page":"1778","DOI":"10.1002\/art.40579","article-title":"Phase II study of ABT-122, a tumor necrosis factor- and interleukin-17A-targeted dual variable domain immunoglobulin, in patients with psoriatic arthritis with an inadequate response to methotrexate","volume":"70","author":"Mease","year":"2018","journal-title":"Arthritis Rheumatol"},{"key":"2025090313063207000_10.1.e003809.39","doi-asserted-by":"publisher","DOI":"10.3899\/jrheum.180267"},{"key":"2025090313063207000_10.1.e003809.40","doi-asserted-by":"publisher","DOI":"10.3899\/jrheum.180249"},{"key":"2025090313063207000_10.1.e003809.41","doi-asserted-by":"publisher","DOI":"10.3899\/jrheum.2023-0530"},{"key":"2025090313063207000_10.1.e003809.42","doi-asserted-by":"crossref","first-page":"1430","DOI":"10.1002\/acr.24593","article-title":"Depression and anxiety reduce the probability of achieving a state of sustained minimal disease activity in patients with psoriatic arthritis","volume":"74","author":"Wong","year":"2022","journal-title":"Arthritis Care Res (Hoboken)"},{"key":"2025090313063207000_10.1.e003809.43","doi-asserted-by":"publisher","DOI":"10.1111\/jdv.13306"},{"key":"2025090313063207000_10.1.e003809.44","doi-asserted-by":"crossref","first-page":"1599","DOI":"10.1093\/rheumatology\/kez505","article-title":"Comorbid fibromyalgia impairs the effectiveness of biologic drugs in patients with psoriatic arthritis","volume":"59","author":"Iannone","year":"2020","journal-title":"Rheumatology (Oxford)"},{"key":"2025090313063207000_10.1.e003809.45","doi-asserted-by":"crossref","DOI":"10.1136\/rmdopen-2022-002718","article-title":"Sex differences in the efficacy, safety and persistence of patients with Psoriatic arthritis treated with tofacitinib: a post-hoc analysis of phase 3 trials and long-term extension","volume":"9","author":"Eder","year":"2023","journal-title":"RMD Open"},{"key":"2025090313063207000_10.1.e003809.46","doi-asserted-by":"crossref","first-page":"447","DOI":"10.1007\/s40744-020-00215-6","article-title":"Obesity and psoriatic arthritis: a narrative review","volume":"7","author":"Kumthekar","year":"2020","journal-title":"Rheumatol Ther"},{"key":"2025090313063207000_10.1.e003809.47","doi-asserted-by":"publisher","DOI":"10.1136\/annrheumdis-2017-212862"},{"key":"2025090313063207000_10.1.e003809.48","doi-asserted-by":"publisher","DOI":"10.3899\/jrheum.220310"},{"key":"2025090313063207000_10.1.e003809.49","doi-asserted-by":"crossref","DOI":"10.1136\/annrheumdis-2023-eular.991","article-title":"Ab1109 treatment retention and safety of Ixekizumab in a population with psoriatic arthritis refractory to biologic and targeted synthetic Dmards","volume":"82","author":"Bra\u00f1a-Abascal","year":"2023","journal-title":"Ann Rheum Dis"}],"container-title":["RMD Open"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/syndication.highwire.org\/content\/doi\/10.1136\/rmdopen-2023-003809","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,9,3]],"date-time":"2025-09-03T20:06:40Z","timestamp":1756930000000},"score":1,"resource":{"primary":{"URL":"https:\/\/rmdopen.bmj.com\/lookup\/doi\/10.1136\/rmdopen-2023-003809"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2024,1]]},"references-count":49,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2024,1,8]]},"published-print":{"date-parts":[[2024,1]]}},"alternative-id":["10.1136\/rmdopen-2023-003809"],"URL":"https:\/\/doi.org\/10.1136\/rmdopen-2023-003809","relation":{},"ISSN":["2056-5933"],"issn-type":[{"value":"2056-5933","type":"electronic"}],"subject":[],"published":{"date-parts":[[2024,1]]}}}