Emerging approaches to difficult-to-manage axial spondyloarthritis

Management of D2M axSpA should shift from a 'next biologic' to a 'right mechanism' paradigm, with mechanistic stratification informing treatment allocation. Patients with TR-axSpA warrant pharmacological escalation or novel therapeutic approaches; conversely, the majority of D2M patients require multidisciplinary care prioritizing evidence-based non-pharmacological interventions, which are substantially underutilized despite robust efficacy data. This must be underpinned by further research targeting D2M axSpA cohorts.