Reaching the disease-activity target is not the same as feeling well in axial spondyloarthritis

People with axial spondyloarthritis who reach a widely used disease-activity target at 12 months often still report substantial symptoms, according to a retrospective analysis of a single-center, IRB-approved Saudi registry cohort published in Advances in Rheumatology. Among 160 patients, 102 (63.7%) met the ASDAS-CRP low-disease-activity threshold of below 2.1 at 12 months, yet 70 of those 102 patients (68.6%; 95% CI 59.1–76.8) still scored at least 4 out of 10 on at least one individual BASDAI item, an exploratory residual-symptom criterion the authors prespecified. A stricter threshold of at least 5 out of 10 on any item was met by 41 of the 102 patients (40.2%; 95% CI 31.2–49.9).

The study included adults meeting ASAS classification criteria who had complete BASDAI item assessments at both baseline and 12 months. Baseline represented the first targeted-therapy initiation for 134 of the 160 patients (83.8%) and a first eligible routine assessment under NSAID or non-targeted management for 26 (16.3%); no baseline was anchored to a treatment switch. All six BASDAI items improved over the 12 months, with paired Wilcoxon signed-rank tests showing improvement for every item after false discovery rate correction (all q < 0.001), and standardized response means were also reported. In a sensitivity analysis restricted to the 151 patients whose baseline ASDAS-CRP was at least 2.1, 93 (61.6%) attained low disease activity at 12 months, and 65 of those 93 (69.9%) met the exploratory at-least-4 criterion.

The authors emphasized that the item-level criterion was operationally defined for this study and is not validated for individual BASDAI items, and that meeting it does not establish ongoing inflammatory activity or failure of the ASDAS target. ASDAS-CRP is anchored on C-reactive protein, and the treat-to-target approach in axial spondyloarthritis defines low disease activity as an ASDAS-CRP below 2.1, but the study’s central point is that reaching that target does not necessarily imply symptom resolution. The prespecified primary endpoint was this pragmatic, exploratory criterion, and the analysis also examined a targeted-therapy-exposure subset, baseline-context subgroups, and exploratory Firth penalized logistic associations, including a model refit after excluding patients classified as having fibromyalgia.

In the exploratory modeling, higher baseline mean item burden was associated with meeting the residual-symptom criterion, with an odds ratio of 1.79 per point (95% CI 1.16–2.77), and the estimate was similar after excluding patients classified as having fibromyalgia (OR 1.80; 95% CI 1.16–2.80). The authors concluded that ASDAS-LDA at 12 months frequently coexisted with patient-reported BASDAI item burden, and that these findings support symptom review and mechanism-directed assessment when symptoms persist despite meeting the target. As a retrospective single-center registry analysis, the study describes associations within one Saudi cohort rather than testing the efficacy of any treatment strategy, and the residual-symptom threshold itself remains exploratory.

Subject of Research: Residual patient-reported symptom burden among axial spondyloarthritis patients meeting the ASDAS low-disease-activity target at 12 months

Article Title: Meeting the ASDAS low-disease-activity target but not symptom-free: item-level residual symptom burden at 12 months in a Saudi axial spondyloarthritis cohort

Article References: Bedaiwi, M., Aboabat, A., Almaghlouth, I., Alshafi, N., & Alqurtas, E. (2026). Meeting the ASDAS low-disease-activity target but not symptom-free: item-level residual symptom burden at 12 months in a Saudi axial spondyloarthritis cohort. Advances in Rheumatology. https://doi.org/10.1186/s42358-026-00587-3

Image Credits: AI Generated

DOI: 10.1186/s42358-026-00587-3

Keywords: axial spondyloarthritis, ASDAS, BASDAI, low disease activity, treat-to-target, residual symptoms, patient-reported outcomes, Saudi cohort, registry study, rheumatology, Meeting, low-disease-activity