{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,7]],"date-time":"2026-09-07T14:07:43Z","timestamp":1788790063411,"version":"build-2803163510"},"reference-count":26,"publisher":"BMJ","issue":"3","license":[{"start":{"date-parts":[[2026,9,7]],"date-time":"2026-09-07T00:00:00Z","timestamp":1788739200000},"content-version":"unspecified","delay-in-days":68,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["RMD Open"],"accepted":{"date-parts":[[2026,7,25]]},"published-print":{"date-parts":[[2026,7]]},"abstract":"<jats:sec>\n                    <jats:title>Objective<\/jats:title>\n                    <jats:p>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.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>Patients from the French prospective DESIR (DEvenir des Spondyloarthrites Indiff\u00e9renci\u00e9es R\u00e9centes) cohort fulfilling the Assessment of Spondyloarthritis International Society (ASAS) 2009 criteria for axSpA and exposed to \u22651 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 \u22653 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.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Among 177 patients exposed to \u22651 bDMARD, the cumulative incidence of D2M-axSpA was 6.8% (95% CI 2.4 to 11.0)\u2009and 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)\u2009and opioid use (100% vs 72%).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>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.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Trial registration number<\/jats:title>\n                    <jats:p>\n                      <jats:ext-link xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" ext-link-type=\"clintrialgov\" xlink:href=\"NCT01648907\">NCT01648907<\/jats:ext-link>\n                      .\n                    <\/jats:p>\n                  <\/jats:sec>","DOI":"10.1136\/rmdopen-2026-007094","type":"journal-article","created":{"date-parts":[[2026,9,7]],"date-time":"2026-09-07T13:10:20Z","timestamp":1788786620000},"page":"e007094","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":0,"title":["Incidence, baseline-associated factors and burden of difficult-to-manage axial spondyloarthritis: a 10-year analysis of the DESIR cohort"],"prefix":"10.1136","volume":"12","clinical-trial-number":[{"clinical-trial-number":"nct01648907","registry":"10.18810\/clinical-trials-gov"},{"clinical-trial-number":"nct01648907","registry":"10.18810\/clinical-trials-gov"}],"author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-5026-7905","authenticated-orcid":false,"given":"Olivier","family":"Fakih","sequence":"first","affiliation":[{"name":"Universit\u00e9 Marie et Louis Pasteur, Service de rhumatologie, CHU de Besan\u00e7on, Besan\u00e7on, France"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2246-1986","authenticated-orcid":false,"given":"Anna","family":"Molt\u00f3","sequence":"additional","affiliation":[{"name":"INSERM, INRAE, Centre for Research in Epidemiology and Statistics, Universit\u00e9 Paris Cit\u00e9 and Universit\u00e9 Sorbonne Paris Nord, Paris, France"},{"name":"Rheumatology Department, Bichat Hospital, AP-HP, Paris, 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