{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,5,4]],"date-time":"2026-05-04T01:54:09Z","timestamp":1777859649162,"version":"3.51.4"},"reference-count":30,"publisher":"SAGE Publications","issue":"2","license":[{"start":{"date-parts":[[2025,10,29]],"date-time":"2025-10-29T00:00:00Z","timestamp":1761696000000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/journals.sagepub.com\/page\/policies\/text-and-data-mining-license"}],"content-domain":{"domain":["journals.sagepub.com"],"crossmark-restriction":true},"short-container-title":["Journal of Psoriasis and Psoriatic Arthritis\u00ae"],"published-print":{"date-parts":[[2026,4]]},"abstract":"<jats:sec>\n                    <jats:title>Objective<\/jats:title>\n                    <jats:p>To assess the contributing factors and clinical characteristics of difficult-to-treat (D2T) psoriatic arthritis (PsA).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Patients and methods<\/jats:title>\n                    <jats:p>This retrospective cross-sectional study included PsA patients from a tertiary care center. D2T PsA was defined as failure of at least 1 conventional synthetic DMARD (csDMARD) and 2 or more biologic\/targeted synthetic DMARDs (b\/tsDMARDs) with different mechanisms of action. Baseline demographics, disease duration, and domain involvement were compared across groups.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      A total of 150 PsA patients were included, with an equal gender distribution and a mean age of 55.9 \u00b1 13.7\u00a0years. Patients with D2T PsA had a significantly younger age of onset for both psoriasis and PsA (both\n                      <jats:italic toggle=\"yes\">P<\/jats:italic>\n                      &lt; 0.001), and a higher prevalence of obesity (\n                      <jats:italic toggle=\"yes\">P<\/jats:italic>\n                      = 0.018). Multidomain involvement was prominent, with 93.5% of D2T patients having 3 or more domains affected (\n                      <jats:italic toggle=\"yes\">P<\/jats:italic>\n                      &lt; 0.001). Axial disease, dactylitis, enthesitis, and nail involvement were all significantly more frequent in the D2T group (all\n                      <jats:italic toggle=\"yes\">P<\/jats:italic>\n                      &lt; 0.001). Multivariate analysis identified age, age of psoriasis onset, axial involvement, enthesitis, and nail dystrophy as independent predictors of D2T PsA.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>D2T PsA is associated with early disease onset, obesity, and extensive multi-domain involvement, particularly axial disease, enthesitis, and nail changes. These findings suggest that specific clinical features and comorbidities may help identify patients at risk of developing D2T PsA. Early recognition of these factors may guide more personalized and aggressive treatment strategies to improve long-term outcomes.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1177\/24755303251394308","type":"journal-article","created":{"date-parts":[[2025,10,29]],"date-time":"2025-10-29T23:58:30Z","timestamp":1761782310000},"page":"46-52","update-policy":"https:\/\/doi.org\/10.1177\/sage-journals-update-policy","source":"Crossref","is-referenced-by-count":1,"title":["Characteristics and Contributing Factors for Difficult to Treat Psoriatic Arthritis- a Comparative Analysis"],"prefix":"10.1177","volume":"11","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-1114-6924","authenticated-orcid":false,"given":"Ong","family":"Ping Seung","sequence":"first","affiliation":[{"name":"Hospital Raja Permaisuri Bainun"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Lee Pei","family":"Jia","sequence":"additional","affiliation":[{"name":"Hospital Raja Permaisuri Bainun"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"179","published-online":{"date-parts":[[2025,10,29]]},"reference":[{"key":"e_1_3_6_2_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.rdc.2015.07.003"},{"key":"e_1_3_6_3_2","doi-asserted-by":"publisher","DOI":"10.1002\/acr.23094"},{"key":"e_1_3_6_4_2","doi-asserted-by":"publisher","DOI":"10.1136\/annrheumdis-2014-205675"},{"key":"e_1_3_6_5_2","doi-asserted-by":"publisher","DOI":"10.1016\/S0140-6736(15)00347-5"},{"key":"e_1_3_6_6_2","doi-asserted-by":"publisher","DOI":"10.1016\/S0140-6736(18)30949-8"},{"key":"e_1_3_6_7_2","doi-asserted-by":"publisher","DOI":"10.1093\/rheumatology\/keab233"},{"key":"e_1_3_6_8_2","doi-asserted-by":"publisher","DOI":"10.1136\/annrheumdis-2020-217344"},{"key":"e_1_3_6_9_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.ard.2025.06.619"},{"key":"e_1_3_6_10_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.ard.2025.05.188"},{"key":"e_1_3_6_11_2","doi-asserted-by":"publisher","DOI":"10.1007\/s40744-022-00461-w"},{"key":"e_1_3_6_12_2","doi-asserted-by":"publisher","DOI":"10.1002\/art.21972"},{"key":"e_1_3_6_13_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.amjmed.2018.05.013"},{"key":"e_1_3_6_14_2","doi-asserted-by":"publisher","DOI":"10.1093\/rheumatology\/keae263"},{"key":"e_1_3_6_15_2","doi-asserted-by":"publisher","DOI":"10.1002\/acr.20627"},{"key":"e_1_3_6_16_2","doi-asserted-by":"publisher","DOI":"10.1177\/1759720X241295920"},{"key":"e_1_3_6_17_2","doi-asserted-by":"publisher","DOI":"10.1136\/bmjopen-2022-061474"},{"key":"e_1_3_6_18_2","doi-asserted-by":"publisher","DOI":"10.1136\/ard-2024-225531"},{"key":"e_1_3_6_19_2","doi-asserted-by":"publisher","DOI":"10.1002\/art.40726"},{"issue":"61","key":"e_1_3_6_20_2","first-page":"S85","article-title":"Use of MTX in the elderly and in patients with compromised renal function","volume":"5","author":"Morgacheva O","year":"2010","unstructured":"Morgacheva O, Furst DE. Use of MTX in the elderly and in patients with compromised renal function. Clin Exp Rheumatol. 2010;5(Suppl 61):S85-S94.","journal-title":"Clin Exp Rheumatol"},{"key":"e_1_3_6_21_2","doi-asserted-by":"publisher","DOI":"10.1136\/ard.2008.094730"},{"key":"e_1_3_6_22_2","doi-asserted-by":"publisher","DOI":"10.1136\/ard.2005.051144"},{"key":"e_1_3_6_23_2","doi-asserted-by":"publisher","DOI":"10.1136\/ard.2005.039826"},{"key":"e_1_3_6_24_2","doi-asserted-by":"publisher","DOI":"10.1002\/art.21177"},{"key":"e_1_3_6_25_2","doi-asserted-by":"publisher","DOI":"10.3899\/jrheum.200371"},{"key":"e_1_3_6_26_2","first-page":"1251","article-title":"New GRAPPA and EULAR recommendations for the management of psoriatic arthritis","volume":"56","author":"Coates LC","year":"2017","unstructured":"Coates LC, Gossec L, Ramiro S, et al. New GRAPPA and EULAR recommendations for the management of psoriatic arthritis. 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