Patients with poorer health status are more likely to have difficult-to-manage axial spondyloarthritis: insights from a real-world cohort

Background: Predicting difficult-to-manage (D2M) axSpA remains challenging, as both inflammatory and non-inflammatory factors contribute to treatment failure. Functional impairment captured by Health Assessment Questionnaire–Disability Index (HAQ-DI) and Multidimensional Health Assessment Questionnaire (MDHAQ) may provide additional predictive value, but are rarely evaluated in this context. Objectives: To assess the predictive value of HAQ-DI and MDHAQ for identifying patients at risk of D2M axSpA in real-world clinical practice. Design: Single-center retrospective observational study based on data from a clinical registry. Methods: The study included patients with axSpA initiating biologic or targeted synthetic disease-modifying antirheumatic drugs. Data included demographic, clinical, and laboratory parameters, as well as patient-reported outcomes. D2M status was defined according to the Assessment of SpondyloArthritis International Society (ASAS) criteria. Health status was evaluated using HAQ-DI and MDHAQ. Logistic regression identified predictors of D2M status at baseline, 24 and 48 weeks. Results: The cohort included 300 treatment courses in 217 patients (average age 45 years, 49% female, 83% HLA-B27 positive, 83% r-axSpA). At baseline, 11% patients met ASAS criteria for D2M axSpA, decreasing to 8.8% at week 48. D2M patients were older ( p = 0.03), exercised less frequently ( p = 0.04) and had higher disease activity. In multivariable models, baseline HAQ-DI independently predicted D2M status at baseline (OR 3.29, p = 0.008) and week 24 (OR 4.56, p = 0.005) and functional dimension of MDHAQ at week 24 (OR 3.47, p = 0.039). Conclusion: Functional impairment, reflected by higher HAQ-DI and MDHAQ scores, was the strongest predictor of D2M axSpA and may serve as a valuable tool for identifying these patients early and addressing nonpharmacological management strategies ahead.