Axial spondyloarthritis (axSpA) is a debilitating inflammatory state exhibiting poor patient-reported outcomes (PRO) and leading to the great diminution in the quality of life. However, axSpA patients with poor PRO show meaningful response and retention against treatment with tumour necrosis factor inhibitor is not well known, and the following trial highlights the role of poor PRO on treatment outcomes.

To examine whether patients with axial spondyloarthritis (axSpA) and remarkably reduced patient-reported outcomes (PROs) during the first tumour necrosis factor inhibitor (TNFi) therapy have inadequate treatment response and shorter treatment retention as compared to other patients.

An observational cohort analysis involved axSpA patients who started their first TNFi from 2011 to 2016. These patients were ranked as per the baseline Bath Ankylosing Spondylitis Disease Activity Index (BASDAI ≥ 0.0 to ≤ 4.0, > 4.0 to ≤ 5.0, > 5.0 to ≤ 6.0, > 6.0 to ≤ 7.0, > 7.0 to ≤ 8.0, > 8.0 to ≤ 9.0, and > 9.0 to ≤ 10.0). The BASDAI > 9.0 to ≤ 10.0 considered as an extremely poor BASDAI. Log-rank and chi-squared tests were used to measure treatment responses (≥ 40% improvement in Assessment of SpondyloArthritis international Society (ASAS40) response, and ASAS partial remission, and ≥ 50% improvement from baseline BASDAI (BASDAI50)) after six months and the retention rates, respectively. Similar investigations were done for patient global score, Bath Ankylosing Spondylitis Functional Index (BASFI), and pain score.

A total of 1396 patients with a mean age of 39 years were selected. The women, patients with human leucocyte antigen-B27 negative/higher body mass index or smokers, exhibited notably poor baseline BASDAI [63 patients (5%)]. Patients with extremely poor BASDAI showed poorer response rates as compared to other patients. (ASAS40 16% and 35%, p = 0.002; ASAS partial remission 6% and 22%, BASDAI50 19% and 41%, p < 0.001, respectively). The one-year treatment retention was also lower among the patients with extremely poor BASDAI (51% and 68%, p < 0.001). Broadly comparable outcomes were observed for patients with remarkably poor pain score, patient global and BASFI scores.

Patients who proclaimed remarkably substantial symptom burden at baseline had a low retention rate and reduced response rates. In these instances, competing causes of pain should be taken into account carefully when analysing treatment with TNFi.