Unraveling the Challenges of Difficult-to-Treat Spondyloarthritis: SPARTAN 2024 Annual Meeting Proceedings.

Purpose of review: This review aims to explore the emerging concept of difficult-to-treat axial spondyloarthritis (D2T-axSpA), including its definitions, clinical challenges, and management strategies. The objective, as presented at the SPARTAN 2024 Annual Meeting, is to delineate the evolving framework for identifying and addressing D2T-axSpA, with a focus on inflammatory and non-inflammatory mechanisms of treatment failure and the implications for clinical practice.

Recent findings: Studies have highlighted a prevalence of D2T-axSpA ranging from 19.5 to 28.3% in real-world cohorts, with associated risk factors including peripheral arthritis, comorbidities, and female gender. Recent advances include the Assessment of SpondyloArthritis International Society's (ASAS) preliminary definition of "difficult-to-manage axSpA" (D2M-axSpA), which encompasses treatment-refractory cases and broader management challenges and `treatment refractory axSpA´ where objective evidence of ongoing inflammation is mandatory.  D2T-axSpA presents significant challenges due to persistent disease activity and the interplay of inflammatory and non-inflammatory drivers. The emerging definitions and research into personalized treatment strategies promise to refine clinical management. Future directions emphasize biomarker-driven precision medicine, novel therapeutic combinations, and holistic care models to improve outcomes in this complex patient population.