Approaches to Difficult-to-Manage Spondyloarthritis

As an interesting side note, Dr. McGonagle discussed studies examining fecal microbiota transplant (FMT) as a potential treatment for PsA. Unfortunately, he said, “These patients had worse outcomes. FMT effectively triggered a reactive arthritis, so the place of FMT in these patients isn’t clear.”¹⁰

Ultimately, when it comes to truly refractory patients, Dr. McGonagle shared, “I focus not on sequential monotherapy but move toward combination therapy. This is currently an active game. The game is in play, and we are all part of it.”

In Sum

D2T SpA refers specifically to treatment refractory disease. It’s a subset of D2M SpA, which also involves extrinsic reasons a patient doesn’t feel better, like FM. History, physical exam, labs and imaging (particularly MRI of the sacrum) are vital to differentiating inflammatory, noninflammatory and other extrinsic contributions to disease activity. When a patient isn’t getting better, Dr. McGonagle reminded us that “You’ve got to ask yourself, ‘Did I get it wrong?’” For patients with inflammatory disease truly refractory to biologic monotherapy, combination therapy may be the way to go and continues to be an area of active research.

Samantha C. Shapiro, MD, is a clinician educator who is passionate about the care and education of rheumatology patients. She writes for both medical and lay audiences and practices telerheumatology.

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