Approaches to Difficult-to-Manage Spondyloarthritis

WASHINGTON, D.C.—In my extremely biased opinion, rheumatology is the best specialty on the planet. I could cite hundreds of reasons to back this up, but my personal favorite is our unique ability to give people their lives back. The patient who hasn’t been able to work for months is back on the job. The patient wheelchair bound due to joint pain just walked into clinic for the first time. The patient crying in pain every single day can’t remember the last time they reached for the tissue box.

The list goes on, but every now and then is a patient we just can’t seem to help. What then? At the ACR Convergence 2024 session Approach to Difficult-to-Manage Spondyloarthritis, two experts spoke about identifying difficult-to-manage (D2M) patients with spondyloarthritis (SpA), differentiating active disease from fibromyalgia (FM) and therapy selection in these patients.

Difficult to Manage vs. Difficult to Treat

Liron Caplan, MD, PhD

Liron Caplan, MD, PhD, founder and co-director of the University of Colorado Program to Advance SpA Treatment and associate professor, medicine-rheumatology, University of Colorado Anschutz Medical Campus, Aurora, spoke on Chronic Pain in Spondyloarthritis: Differentiating Active Disease From Fibromyalgia. He kicked off his talk explaining the difference between D2M and difficult-to-treat (D2T) patients. “I think of D2T as synonymous with treatment refractory. The broader concept of D2M can also include extrinsic factors. So, D2T is a subcategory of D2M,” he explained.

To be more specific, D2T SpA speaks to intrinsic factors like nonresponse to medications. D2M SpA also includes extrinsic factors that prevent SpA patients from getting better, like:

• other causes of symptoms, like fibromyalgia
• access to care and medications
• medication adherence
• adequate medication dosage relative to patient body mass index
• fear of adverse effects of medication (without actual adverse effects)

Last but not least, Dr. Caplan noted that the diagnosis itself needs to be evaluated as an extrinsic factor that might explain why a patient has D2M disease. Perhaps a patient isn’t getting better because the diagnosis isn’t correct.

The Assessment of SpondyloArthritis International Society (ASAS) proposed a definition for D2M spondyloarthritis in an abstract at this year’s ACR Convergence.¹ Dr. Caplan explained, “We are trying to better define these categories to give providers guidance as to minimum standards of care and best practices. We’re also trying to limit inappropriate switching of medications and to provide practitioners a framework for how to understand disease.”