Clinical and Demographic Characteristics of Treatment-Refractory Axial Spondyloarthritis: Data from the Greek AxSpA Registry

Nikolaos Kougkas¹, Konstantinos Tsafis², Dimitrios Deligeorgakis³, Vasileios Papadopoulos⁴, Nikolaos Fytanidis⁵, Michail Krikelis⁶, Evangelia Mole⁷, Sousana Gazi⁷, Nikolaos Koletsos⁸, EVRIPIDIS KALTSONOUDIS⁹, Paraskevi V Voulgari¹⁰, Anastasios Karamanakos¹¹, Maria Pappa¹², Maria Tektonidou¹³, Petros Sfikakis¹⁴, Kalliopi Klavdianou¹⁵, aggelos Banos¹⁶, Eleni Kalavri¹⁷, Konstantinos Kottas¹⁸, Gkikas Katsifis¹⁸, MARIA KONSTA¹⁹, Eleftheria Grika²⁰, Charalampos Sfontouris²⁰, Evgenia Mavrea²¹, Christos Koutsianas²², Evangelia Kataxaki²³, Eleni Sampatakaki²⁴, Konstantina Zoupidou²⁵, Pelagia Katsimpri²⁶, Alexios Iliopoulos²⁷, Georgios Iliopoulos²⁸, Dimitrios Daousis²⁹, Ilias Bournazos³⁰, DIMITRIOS KAROKIS³¹, Dimos Patrikos³², Theodoros Dimitroulas³, Dimitrios Vassilopoulos²¹, George E Fragoulis³³ and Charalampos Papagoras³⁴, ¹⁴th Department of Internal Medicine, Aristotle University, Thessaloniki, Thessaloniki, Greece, ²Hippokration University Hospital, Medical School, Aristotle University of Thessaloniki, Fourth Department of Internal Medicine, Thessaloniki, Greece, Thessaloniki, Thessaloniki, Greece, ³Hippokration University Hospital, Medical School, Aristotle University of Thessaloniki, Fourth Department of Internal Medicine, Thessaloniki, Greece, Thessaloniki, Greece, ⁴Department of Medicine Democritus University of Thrace, Laboratory of Anatomy, Alexandroupolis, Greece, Alexandroupolis, Evros, Greece, ⁵University Hospital of Alexandroupolis, Democritus University of Thrace, First Department of Internal Medicine, Alexandroupolis, Greece, Alexandroupolis, Greece, ⁶KAT Hospital, Athens, Department of Rheumatology, Athens, Greece,, Athens, Attiki, Greece, ⁷Rheumatology department, KAT General Hospital of Attica, Athens, Attiki, Greece, ⁸School of Health Sciences, Faculty of Medicine, University of Ioannina, Department of Rheumatology, Ioannina, Greece, Ioannina, Ioannina, Greece, ⁹Rheumatology Clinic, University of Ioannina, IOANNINA, Ioannina, Greece, ¹⁰Department of Rheumatology, School of Health Sciences, Faculty of Medicine, University of Ioannina, Ioannina, Ioannina, Greece, ¹¹Joint Academic Rheumatology Program, National and Kapodistrian University of Athens, School of Medicine, General Hospital of Athens “Laiko”, First Department of Propedeutic and Internal Medicine, Athens, Greece, Athens, Greece, ¹²Rheumatology and Clinical Immunology Unit, ⁴th Department of Internal Medicine, Joint Academic Rheumatology Program, National and Kapodistrian University of Athens, Athens, Attiki, Greece, ¹³National and Kapodistrian University of Athens, Athens, Greece, ¹⁴NKUA - SCHOOL OF MEDICINE, Athens, Greece, ¹⁵Asklepieion" General Hospital, Athens, Department of Rheumatology, Αthens, Greece, Kaisariani Athens, Greece, ¹⁶Asklepieion" General Hospital, Athens, Department of Rheumatology, Αthens, Greece, Athens, Attiki, Greece, ¹⁷"Asklepieion" General Hospital, Athens, Department of Rheumatology, Αthens, Greece, Athens, Greece, ¹⁸Naval Hospital of Athens, Rheumatology Clinic, Athens, Greece, Athens, Greece, ¹⁹Sismanoglion Hospital, Athens, Greece, Marousi, Attiki, Greece, ²⁰Evaggelismos Athens General Hospital, Department of Rheumatology, Athens, Greece, Athens, Greece, ²¹Joint Academic Rheumatology Program, National and Kapodistrian University of Athens, School of Medicine, General Hospital of Athens “Hippokration”, Clinical Immunology-Rheumatology Unit, ²nd Department of Medicine and Laboratory, Athens, Greece, Athens, Greece, ²²Joint Academic Rheumatology Program, National and Kapodistrian University of Athens, School of Medicine, General Hospital of Athens “Hippokration”, Athens, Greece, ²³General Hospital Elefsinas Thriaseio,Attica, Rheumatology Department, Athens, Greece, Athens, Greece, ²⁴Joint Academic Rheumatology Program, Attikon University Hospital, National and Kapodistrian University of Athens, School of Medicine, ⁴th Department of Internal Medicine, Athens, Greece, Athens, Attiki, Greece, ²⁵Joint Academic Rheumatology Program, Attikon University Hospital, National and Kapodistrian University of Athens, School of Medicine, ⁴th Department of Internal Medicine, Athens, Greece, Athens, Greece, ²⁶Joint Rheumatology Program, University of Athens Medical School, Athens, Greece, ²⁷⁴¹⁷ Army Share Fund Hospital (NIMTS), Department of Rheumatology, Athens, Greece, ZOGRAFOU, Greece, ²⁸Patras University Hospital, University of Patras Medical School, Department of Rheumatology, Patras, Greece, Patras, Akhaia, Greece, ²⁹Patras University Hospital, University of Patras Medical School, Department of Rheumatology, Patras, Greece, Patra, Greece, ³⁰Private practice, Athens, Greece, Athens, Greece, ³¹Private practice, Patras, Greece, Patras, Greece, ³²Private practice, Athens, Greece, Ag. Paraskevi, Greece, ³³First Department of Propedeutic and Internal Medicine, Joint Academic Rheumatology program, National and Kapodistrian University of Athens, Athens, Attiki, Greece, ³⁴First Department of Internal Medicine, University Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Evros, Greece

Meeting: ACR Convergence 2025

Keywords: Ankylosing spondylitis (AS), Comorbidity, Demographics, registry, spondyloarthritis

Session Information

Date: Monday, October 27, 2025

Title: (1434–1466) Spondyloarthritis Including Psoriatic Arthritis – Treatment Poster II

Session Type: Poster Session B

Session Time: 10:30AM-12:30PM

Background/Purpose: Axial spondyloarthritis (AxSpA) is a chronic inflammatory disease that significantly impairs quality of life. Although biologic and targeted synthetic DMARDs (b/tsDMARDs) have improved disease control, a subset of patients remains treatment-refractory (TR), failing to achieve effective control of inflammation despite sequential use of multiple advanced therapies. This TR subgroup forms part of the broader group of difficult-to-manage (D2M) AxSpA patients. ASAS recently proposed a definition for both D2M and TR to guide research into these special populations [1].Objectives To describe the demographic and clinical features of treatment-refractory AxSpA patients in Greece and compare them with the non-TR subgroups.

Methods: Data were retrieved from the Greek AxSpA Registry, a prospective cohort (2022–2023) including patients fulfilling the 1984 modified New York criteria for radiographic AxSpA or the 2009 ASAS criteria for non-radiographic AxSpA. Patients were classified into three groups: non-D2M, D2M non-TR, and TR. TR patients met both of the following criteria: (1) inadequate response, defined as ASDAS ≥2.1 despite treatment with ≥2 b/tsDMARDs with different mechanisms, and (2) objective evidence of persistent inflammation (CRP >0.5 mg/dL). Demographics, clinical, radiographic features and comorbidities were compared among groups.

Results: Out of 395 AxSpA patients included in this analysis, 355 (89.9%) were classified as non-D2M and 40 (10.1%) as D2M, among whom 22 (5.6%) patients met criteria for TR disease. There was no significant difference regarding age, gender, disease duration and proportion of radiographic disease among the three groups (Table 1). However, compared to non-D2M patients, TR patients, as well as non-TR D2M patients, exhibited significantly higher BASDAI, ASDAS, BASFI, Global and Pain VAS (p< 0.001 for all), as well as a higher number of comorbidities (p=0.004). However, depression was more frequent in the non-TR D2M group only (p=0.002). Particularly TR patients had significantly more syndesmophytes, more frequent hip involvement, and were more often overweight and current smokers. Finally, in our cohort all TR patients were HLA B27 positive, compared to 57% of non-TR D2M and 78% of non-D2M patients (p=0.026).

Conclusion: Treatment-refractory AxSpA represents a subgroup of D2M patients with severe disease, characterized by persistent inflammation, functional impairment, more advanced structural damage, despite extensive use of advanced therapies, and multiple comorbidities. Early identification and implementation of tailored multidisciplinary care is needed to improve outcomes in this population.References1 Poddubnyy D et al. The Assessment of SpondyloArthritis International Society (ASAS) Consensus-Based Expert Definition of Difficult-to-Manage, including Treatment-Refractory, Axial Spondyloarthritis. Ann Rheum Dis. 2025;84(4):538-546AcknowledgementThe registry on which this study was based received funding from the Greek Rheumatology Society. The authors are grateful to the study participants

Disclosures: N. Kougkas: None; K. Tsafis: None; D. Deligeorgakis: None; V. Papadopoulos: None; N. Fytanidis: None; M. Krikelis: None; E. Mole: None; S. Gazi: None; N. Koletsos: None; E. KALTSONOUDIS: None; P. Voulgari: None; A. Karamanakos: None; M. Pappa: None; M. Tektonidou: None; P. Sfikakis: None; K. Klavdianou: None; a. Banos: None; E. Kalavri: None; K. Kottas: None; G. Katsifis: None; M. KONSTA: None; E. Grika: None; C. Sfontouris: None; E. Mavrea: None; C. Koutsianas: None; E. Kataxaki: None; E. Sampatakaki: None; K. Zoupidou: None; P. Katsimpri: None; A. Iliopoulos: None; G. Iliopoulos: None; D. Daousis: None; I. Bournazos: None; D. KAROKIS: None; D. Patrikos: None; T. Dimitroulas: None; D. Vassilopoulos: None; G. Fragoulis: None; C. Papagoras: None.

To cite this abstract in AMA style:

Kougkas N, Tsafis K, Deligeorgakis D, Papadopoulos V, Fytanidis N, Krikelis M, Mole E, Gazi S, Koletsos N, KALTSONOUDIS E, Voulgari P, Karamanakos A, Pappa M, Tektonidou M, Sfikakis P, Klavdianou K, Banos a, Kalavri E, Kottas K, Katsifis G, KONSTA M, Grika E, Sfontouris C, Mavrea E, Koutsianas C, Kataxaki E, Sampatakaki E, Zoupidou K, Katsimpri P, Iliopoulos A, Iliopoulos G, Daousis D, Bournazos I, KAROKIS D, Patrikos D, Dimitroulas T, Vassilopoulos D, Fragoulis G, Papagoras C. Clinical and Demographic Characteristics of Treatment-Refractory Axial Spondyloarthritis: Data from the Greek AxSpA Registry [abstract]. Arthritis Rheumatol. 2025; 77 (suppl 9). https://acrabstracts.org/abstract/clinical-and-demographic-characteristics-of-treatment-refractory-axial-spondyloarthritis-data-from-the-greek-axspa-registry/. Accessed .

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