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Objectives: To develop a consensus-based expert definition of difficult-to-manage (D2M) axial spondyloarthritis (axSpA), incorporating treatment-refractory (TR) disease., Methods: A literature review was conducted in 2022 to identify potential definitions for D2M/TR axSpA from prior studies, followed by a 2-round Delphi consensus process conducted in 2022 and 2023 to identify components of D2M axSpA. Based on the results of the Delphi process, a draft of the D2M axSpA definition was developed and presented to the expert task force, including patient representation, and, subsequently, to the Assessment of SpondyloArthritis International Society (ASAS) membership for endorsement in January 2024., Results: Consensus was reached on a D2M definition encapsulating treatment failure (treatment according to the ASAS-European Alliance of Associations for Rheumatology recommendations and failure of ≥2 biological or targeted synthetic disease-modifying antirheumatic drugs with different mechanisms of action unless contraindicated), suboptimal disease control, and physician or patient acknowledgement of problematic signs/symptoms in patients diagnosed with axSpA by the rheumatologist. This definition represents a broad concept that includes various reasons that lead to an unsatisfactory treatment outcome. TR axSpA is covered by the D2M definition but requires a history of treatment failure, the presence of objective signs of inflammatory activity, and the exclusion of noninflammatory reasons for nonresponse. The proposed D2M definition incorporating TR disease was endorsed by ASAS at the annual meeting in January 2024, with 89% votes (109/123) in favour of it., Conclusions: The ASAS D2M axSpA definition, including TR disease, allows for identifying patients with unmet needs, paving the way for further research in this condition and its clinical care improvement., Competing Interests: Competing interests DP has received research support from AbbVie, Eli Lilly, MSD, Novartis, Pfizer, consulting fees from AbbVie, Biocad, Bristol-Myers Squibb, Eli Lilly, Janssen, Moonlake, Novartis, Pfizer, and UCB, and speaker fees from AbbVie, Canon, DKSH, Eli Lilly, Janssen, MSD, Medscape, Novartis, Peervoice, Pfizer, and UCB. DP is a member of the executive committee of ASAS. VN-C has received consultancy/speaker/research grants from AbbVie, Alphasigma, BMS, Fresenius Kabi, Galapagos, Janssen, Eli Lilly, Moonlake, MSD, Novartis, Pfizer, Roche, and UCB. VN-C is a member of the executive committee, executive secretary, and elected president of ASAS. MT: none declared. SA has received consulting fees from Argenx, Bristol-Myers Squibb, Galapagos, and Novartis. SZA has received grants from AbbVie, Eli Lilly, Jannsen, Novartis, Pfizer, and UCB, consulting fees from AbbVie, Eli Lilly, Jannsen, Novartis, Pfizer, and UCB, and honoraria from AbbVie, Eli Lilly, Jannsen, Novartis, Pfizer, and UCB. SB: none declared. FvdB: none declared. CB has received financial support from Novartis, AbbVie, Galapagos, Novartis, Pfizer, and UCB. AC has received grant support from BMS, Lilly, and Novartis, honoraria from Alfa Sigma, AbbVie, Amgen, BMS, Eli Lilly, Galapagos, Novartis, Pfizer, and UCB, and travel/meeting attendance support from AbbVie and UCB. JD: none declared. MD has received grant support from Pfizer, UCB, and AbbVie, consulting fees from Novartis and Pfizer, travel/meeting attendance support from Novartis, and participation on a Data Safety Monitoring Board or Advisory Board for Galapagos. TD has received honoraria from AbbVie, Amgen, Novartis, Koçak, and Lilly and travel/meeting attendance support from Celltrion, Lilly, AbbVie, Amgen, Novartis, and Nobel. BE-Z has received consultancy, research grants, and speaker's honoraria from AbbVie, Amgen, BMS, Eva, Hekma, Janssen, Lilly, MSD, New Bridge, Novartis, Pfizer, Roche, Sanofi-Aventis, Servier, and Sobi. WF has received speaker/consulting fees/grants from Novartis, Janssen and Janssen, GlaxoSmithKline, and Diethelm Keller Siber Hegner (DKSH). FvG has received consulting and speaker fees from AbbVie, ASAS, BMS, Galapagos, Janssen, Lilly, Novartis, Pfizer, and UCB. RG-S has received consultancy/speaker/research grants from AbbVie, BMS, Janssen, Eli Lilly, Novartis, Pfizer, Roche, UCB, GSK, Biogen, Amgen, Raffo, and Adium. MGC has received grant support and travel/meeting attendance support from Novartis. PG: none declared. LG: none declared. SG has received honoraria from AbbVie, Altamedics, Amgen, Eli Lilly, Johnson & Johnson, Krka, Medis, MSD, Novartis, Pfizer, Sandoz, Sobi, Stada, Viatris, Teva, and Zentiva and support for attending meetings/travel from AbbVie, Novartis, and Pfizer. FH: none declared. MK has received honoraria from AbbVie, Amgen, Asahi-Kasei Pharma, Ayumi Pharma, BMS, Chugai, Daiichi-Sankyo, Eisai, Eli Lilly, Gilead, Janssen, Novartis, Ono Pharma, Tanabe-Mitsubishi, and UCB Pharm. RL has received consulting fees from AbbVie, Pfizer, UCB, Eli Lilly, Novartis, Jansen Pharma, and Galapagos, honoraria from UCB and AbbVie, participated in a DSMB for a UCB trial, is ASAS and METEOR board member and director of Joint Imaging BV, and of Rheumatology Consultancy BV. YYL has received speaking fees from AbbVie, DKSH, Janssen, Novartis, and Pfizer. PMM has received honoraria from AbbVie, BMS, Celgene, Eli Lilly, Galapagos, Janssen, MSD, Novartis, Orphazyme Pfizer, Roche, and UCB. HM-O has received research grants from Janssen, Novartis, Pfizer, and UCB and speaker fees/honoraria from AbbVie, Amgen, Biogen, Eli Lilly, Janssen, Moonlake, Novartis, Pfizer, and UCB. BM has received honoraria/participated in advisory boards and/or received speaker fees from IPCA, Cipla, Torrent, RPG Lifesciences, and Novartis. AM has received speaker honoraria/participated in advisory boards, and/or received research grants from Biogen, BMS, UCB, Pfizer, Johnson & Johnson, Novartis, Amgen, Gilead, Galapagos, AbbVie, Lilly, and Pfizer. EN has received speaker honoraria/participated in advisory boards, and/or received research grants from UCB, Pfizer, Gilead, Galapagos, AbbVie, Eli Lilly, Alfasigma, Fresenius, and Pfizer. SR has received research grants and/or consultancy fees from AbbVie, Eli Lilly, Galapagos/Alfasigma, Janssen, MSD, Novartis, Pfizer, Sanofi, and UCB. MR has received consulting and/or speaker fees from AbbVie, Chugai, Boehringer-Ingelheim, Eli Lilly, Janssen, Novartis, and UCB. CGSS has received consulting and speaker fees from AbbVie, Janssen, Novartis, and Pfizer. AS has received speaking and/or consulting fees from AbbVie, Novartis, UCB, and Lilly. Support for attending conferences: Janssen. JW has received research grants, speaker fees, or advisor board from Pfizer, Abbott, AbbVie, Bristol-Myers Squibb, Eli Lilly, JNJ, UCB, MSD, GSK, Chugai, Roche, Celgene, Sanofi-Aventis, and Novartis. XB has received research support from AbbVie, Eli Lilly, and Novartis, consulting fees from AbbVie, Alphasigma, BMS, Eli Lilly, Janssen, Moonlake, Novartis, Pfizer, and UCB, and speaker fees from AbbVie, Alphasigma, BMS, Eli Lilly, Janssen, Medscape, Novartis, Peervoice, Pfizer, and UCB. President of ASAS and EULAR. DvdH has received consulting fees from AbbVie, Alfasigma, Argenx, BMS, Eli Lilly, Grey-Wolf Therapeutics, Janssen, Novartis, Pfizer, Takeda, and UCB Pharma and is director of Imaging Rheumatology bv. DvdH is the associate editor of Annals Rheumatic Diseases, an editorial board member of the Journal of Rheumatology and RMD Open, and an advisor to Assessment of Axial Spondyloarthritis International Society., (Copyright © 2025 The Author(s). Published by Elsevier B.V. All rights reserved.)

Objectives: The purpose of the study was to contribute further to this debated topic by investigating the correlation of magnetic resonance imaging (MRI) findings with the clinical picture in lumbar spondylosis patients., Patients and Methods: This multicenter retrospective study (as part of the epidemiological project of the TLAR-OASG [Turkish League Against Rheumatism-Osteoarthritis Study Group]) included 514 patients (101 males, 413 females; mean age: 63.6±10.8 years; range, 40 to 85 years) who were diagnosed as lumbar spondylosis by clinical examination and direct X-ray between December 2016 and June 2018. Demographic characteristics of patients, Visual Analog Scale for pain, presence of radiating pain, Roland-Morris disability questionnaire, straight leg raise test, deep tendon reflexes, neurogenic intermittent claudication symptoms, any decrease of muscle strength, and abnormality of sensation were recorded. Lumbar MRI findings of the patients were recorded as positive or negative in terms of disc herniation, intervertebral disc degeneration, root compression, osteophytes, spinal stenosis. Statistical analysis was done to assess the correlation between the clinical symptoms, physical examination, and MRI findings., Results: Correlation analysis of the MRI results and the clinical findings showed a significant correlation between straight leg raise test and root compression (p<0.001, r=0.328) and a significant correlation between neurogenic intermittent claudication and spinal stenosis (p<0.001, r=0.376). Roland-Morris disability questionnaire had a significant correlation with all MRI findings (p<0.05, r<0.200)., Conclusion: The results of this study corroborate the notion that diligent patient history and physical examination are more valuable than MRI findings, even though a higher incidence of abnormal MRI findings have been obtained in patients with disability and dermatomal radiating pain., Competing Interests: Conflict of Interest: The authors declared no conflicts of interest with respect to the authorship and/or publication of this article., (Copyright © 2023, Turkish League Against Rheumatism.)

Objective: To identify clusters of peripheral involvement according to the specific location of peripheral manifestations (ie, arthritis, enthesitis and dactylitis) in patients with spondyloarthritis (SpA) including psoriatic arthritis (PsA), and to evaluate whether these clusters correspond with the clinical diagnosis of a rheumatologist., Methods: Cross-sectional study with 24 participating countries. Consecutive patients diagnosed by their rheumatologist as PsA, axial SpA or peripheral SpA were enrolled. Four different cluster analyses were conducted: one using information on the specific location from all the peripheral manifestations, and a cluster analysis for each peripheral manifestation, separately. Multiple correspondence analyses and k-means clustering methods were used. Distribution of peripheral manifestations and clinical characteristics were compared across the different clusters., Results: The different cluster analyses performed in the 4465 patients clearly distinguished a predominantly axial phenotype (cluster 1) and a predominantly peripheral phenotype (cluster 2). In the predominantly axial phenotype, hip involvement and lower limb large joint arthritis, heel enthesitis and lack of dactylitis were more prevalent. In the predominantly peripheral phenotype, different subgroups were distinguished based on the type and location of peripheral involvement: a predominantly involvement of upper versus lower limbs joints, a predominantly axial enthesitis versus peripheral enthesitis, and predominantly finger versus toe involvement in dactylitis. A poor agreement between the clusters and the rheumatologist's diagnosis as well as with the classification criteria was found., Conclusion: These results suggest the presence of two main phenotypes (predominantly axial and predominantly peripheral) based on the presence and location of the peripheral manifestations., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: To explore the impact of early versus late-onset psoriasis (PsO) on the disease characteristics of psoriatic arthritis (PsA) in a large-multicentre cohort., Methods: The data from a multicentre psoriatic arthritis database was analysed. Patients were grouped according to age at psoriasis onset (early onset; <40 years of age, late-onset; >40 years of age) and disease characteristics of the groups were compared by adjusting for BMI and PsA duration, where necessary., Results: At the time of analyses, 1634 patients were recruited [62.8% females; early onset 1108 (67.8%); late-onset, 526 (32.2%)]. The late-onset group was more over-weight [66.8% vs. 86.8%, p<0.001; adjusted for age - aOR 1.55 (1.11-2.20; 95% CI)]. The early onset group had more scalp psoriasis at onset (56.7% vs. 43.0%, p<0.001), whereas extremity lesions were more common in the late-onset group (63.8% vs. 74.2%, p<0.001). Axial disease in males and psoriatic disease family history in females were significantly higher in the early onset group [38.0% vs. 25.4%; p=0.005; adjusted for PsA duration - aOR 1.76 (1.19-2.62; 95% CI) / 39.5% vs. 30.1%; p=0.003; OR 1.51 (1.15-1.99; 95% CI), respectively]. Psoriatic disease activity parameters, patient-physician reported outcomes and HAQ-DI scores were similar in both groups., Conclusions: Clinical features of PsA may be affected by the age at onset of PsO. Different genetic backgrounds in early and late-onset PsO may be driving the differences in psoriasis and PsA phenotypes.

Objectives: To characterise peripheral musculoskeletal involvement in patients with spondyloarthritis (SpA) including psoriatic arthritis (PsA), across the world., Methods: Cross-sectional study with 24 participating countries. Patients with a diagnosis of axial SpA (axSpA), peripheral SpA (pSpA) or PsA according to their rheumatologist were included. The investigators were asked which diagnosis out of a list of six (axSpA, PsA, pSpA, inflammatory bowel disease-associated SpA, reactive arthritis or juvenile SpA (Juv-SpA)) fitted the patient best. Peripheral manifestations (ie, peripheral joint disease, enthesitis, dactylitis and root joint disease), their localisation and treatments were evaluated., Results: A total of 4465 patients were included (61% men, mean age 44.5 years) from four geographic areas: Latin America (n=538), Europe plus North America (n=1677), Asia (n=975) and the Middle East plus North Africa (n=1275). Of those, 78% had ever suffered from at least one peripheral musculoskeletal manifestation; 57% had peripheral joint disease, 44% had enthesitis and 15% had dactylitis. Latin American had far more often peripheral joint disease (80%) than patients from other areas. Patients with PsA had predominantly upper limb and small joint involvement (52%).Hip and shoulder involvement was found in 34% of patients. The prevalence of enthesitis ranged between 41% in patients with axSpA and 65% in patients with Juv-SpA. Dactylitis was most frequent among patients with PsA (37%)., Conclusion: These results suggest that all peripheral features can be found in all subtypes of SpA, and that differences are quantitative rather than qualitative. In a high proportion of patients, axial and peripheral manifestations coincided. These findings reconfirm SpA clinical subtypes are descendants of the same underlying disease, called SpA., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: This study aims to explore the accordance to the 2018 European League Against Rheumatism (EULAR) recommendations for the management of hand osteoarthritis (OA) among the Turkish League Against Rheumatism (TLAR) expert panel and composition of TLAR recommendations for the management of hand OA under guidance of the current literature., Materials and Methods: The TLAR convener designated an expert panel of 10 physicians experienced in hand OA for this process. The 2018 EULAR recommendations for the management of hand OA and the systematic review of the literature were sent to the expert panel via e-mails. The e-mail process which included Delphi round surveys was completed. The EULAR standard operational procedure Appraisal of Guidelines for Research and Evaluation II was followed. The level of agreement was calculated for each item and presented as mean, standard deviations, minimum and maximum and comparisons of 2018 EULAR recommendations were performed., Results: Five overarching principles and 10 recommendations were discussed. Revisions were held for the sixth, seventh, and ninth recommendations with lowest level of agreements. These recommendations were revised in accordance with suggestions from the experts and re-voted. The revised forms were approved despite the lack of statistically significant difference between these forms (p=0.400, p=0.451, p=0.496, respectively). Except for the ninth recommendation about surgery (p=0.008), no significant difference in level of agreements was observed between the EULAR and TLAR hand OA recommendations. The 11th recommendation about paraffin bath was added., Conclusion: The optimal treatment of hand OA consists of personalized non-pharmacological (self-management, exercise, splint), pharmacological (topical non-steroidal anti-inflammatory drugs as the first choice), and interventional procedures (only for refractory cases) based on shared decision between the patient and physician. TLAR hand OA recommendations were created mainly based on the most recent literature and the last EULAR hand OA management recommendations, which are widely approved among the TLAR experts., Competing Interests: Conflict of Interest: The authors declared no conflicts of interest with respect to the authorship and/or publication of this article., (Copyright © 2020, Turkish League Against Rheumatism.)

Objectives: This study aims to establish the first national treatment recommendations by the Turkish League Against Rheumatism (TLAR) for psoriatic arthritis (PsA) based on the current evidence., Patients and Methods: A systematic literature review was performed regarding the management of PsA. The TLAR expert committee consisted of 13 rheumatologists and 12 physical medicine and rehabilitation specialists experienced in the treatment and care of patients with PsA from 22 centers. The TLAR recommendations were built on those of European League Against Rheumatism (EULAR) 2015. Levels of evidence and agreement were determined., Results: Recommendations included five overarching principles and 13 recommendations covering therapies for PsA, particularly focusing on musculoskeletal involvement. Level of agreement was greater than eight for each item., Conclusion: This is the first paper that summarizes the recommendations of TLAR as regards the treatment of PsA. We believe that this paper provides Turkish physicians dealing with PsA patients a practical guide in their routine clinical practice., Competing Interests: Conflict of Interest: The authors declared no conflicts of interest with respect to the authorship and/or publication of this article.

Objectives: This study aims to update 2011 Turkish League Against Rheumatism SpondyloArthritis Recommendations, and to compose a national expert opinion on management of axial spondyloArthritis under guidance of current guidelines, and implantation and dissemination of these international guidelines into our clinical practice., Patients and Methods: A scientific committee of 28 experts consisting of 14 rheumatologists and 14 physical medicine and rehabilitation specialists (one of them also has an immunology PhD) was formed. The recommendations, systematic reviews, and meta-analyses including pharmacologic and non-pharmacologic treatment were scrutinized paying special attention with convenient key words. The draft of Turkish League Against Rheumatism opinion whose roof consisted of international treatment recommendations, particularly the Assessment of SpondyloArthritis International Society/European League Against Rheumatism recommendations was composed. Assessment of level of agreement with opinions by task force members was established through the Delphi technique. Voting using a numerical rating scale assessed the strength of each recommendation., Results: Panel compromised on five basic principles and 13 recommendations including pharmacological and nonpharmacological methods. All of the recommendations had adequate strength., Conclusion: Turkish League Against Rheumatism expert opinion for the management of axial spondyloArthritis was developed based on scientific evidence. These recommendations will be updated regularly in accordance with current developments., Competing Interests: Conflict of Interest: The authors declared no conflicts of interest with respect to the authorship and/or publication of this article.

Objectives: This study aims to estimate the prevalence of rheumatoid arthritis (RA) and spondyloarthritis (SpA) in Turkey using the same telephone questionnaire developed for screening RA and SpA in France and used in Serbia and Lithuania., Material and Methods: The study was performed in two steps. In step I, the French questionnaire was translated into Turkish and validated through a group of 200 patients (80 males, 120 females; mean age 44.0±13.1 years; range 19 to 75 years) followed up at the rheumatology departments of University Hospitals in Antalya and Ankara. In step II, the validated Turkish questionnaire was administered face-to-face to randomly selected 4,012 subjects (1,670 males, 2,342 females; mean age 41.5±16.8 years; range 16 to 97 years) by trained general practitioners across the country, in 25 prov- inces for case detection. The subjects who were suspected of having RA or SpA in accordance with the questionnaire were invited to the nearest university hospital for rheumatologic examination in order to confirm the diagnosis., Results: In step II, a total of 25 subjects (2 males, 23 females) were diagnosed as RA. The standardized RA prevalence for the general population of Turkey was calculated as 0.56% (95% confidence interval [CI]; 0.33-0.79), 0.10% (95% CI; -0.05-0.25) for males and 0.89% (95% CI; 0.51-1.27) for females. A total of 18 subjects (3 males, 15 females) were diagnosed as SpA. The standardized SpA prevalence for the general population of Turkey was 0.46% (95% CI; 0.25-0.67), 0.17% (95% CI; -0.03-0.37) for males and 0.65% (95% CI; 0.32-0.98) for females. The prevalence of RA was highest in the Northern region (2.00%) and the prevalence of SpA was highest in the Central region (1.49%)., Conclusion: The prevalences of RA and SpA in Turkey are close to each other and there are significant inter-regional variations in prevalences of both RA and SpA., Competing Interests: Conflict of Interest: The authors declared no conflicts of interest with respect to the authorship and/or publication of this article.

A web-based application patient follow-up program was developed to create a registry of patients with ankylosing spondylitis (AS) by the Turkiye Romatizma Arastirma Savas Dernegi (TRASD) AS Study Group. This study describes the methodological background and patient characteristics. The patient follow-up program is a web-based questionnaire, which contains sections on socio-demographic data, anamnesis, personal and family history, systemic and musculoskeletal examination, laboratory and imaging data and treatment. Between October 1, 2007 and February 28, 2009, 1,381 patients from 41 centers were included in the registry (1,038 males [75.2%]; mean age 39.5 ± 10.7 years). Mean disease duration was 12.1 ± 8.5 years, and mean time from initial symptom to diagnosis was 5 ± 6.8 years (median 2 years). HLA-B27 positivity was detected in 73.7% of 262 patients tested. Manifestations of extraarticular involvement were anterior uveitis (13.2%), psoriasis and other skin and mucous membrane lesions (6%) and inflammatory bowel disease (3.8%). The prevalence of peripheral arthritis was 11.2%. In 51.7% of patients, the Bath AS Disease Activity Index was ≥4. But since our patients consisted of the ones with more severe disease who referred to the tertiary centers and needed a regular follow-up, they may not represent the general AS population. Disease-modifying anti-rheumatic drugs were being used by 41.9% of patients, with 16.4% using anti-TNF agents. TRASD-IP (Izlem Programi: Follow-up program) is the first AS registry in Turkey. Such databases are very useful and provide a basis for data collection from large numbers of subjects. TRASD-IP gives information on the clinical and demographic profiles of patients, and the efficacy and safety of anti-TNF drugs, examines the impact on quality of life, and provides real-life data that may be used in cost-effectiveness analyses.

Objectives: To evaluate quality of life (QoL) and related variables in patients with ankylosing spondylitis (AS), a chronic inflammatory disease of the spine., Methods: Nine-hundred and sixty-two patients with AS from the Turkish League Against Rheumatism AS Registry, who fulfilled the modified New York criteria, were enrolled. The patients were evaluated using the Assessment of SpondyloArthritis International Society core outcome domains including Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), fatigue (BASDAI-question 1), pain (last week/spine/due to AS), Bath Ankylosing Spondylitis Functional Index (BASFI), Bath Ankylosing Spondylitis Metrology Index (BASMI), Bath Ankylosing Spondylitis Radiology Index (BASRI), Maastricht Ankylosing Spondylitis Enthesitis Score (MASES) and two QoL questionnaires (the disease-specific ASQoL and generic the Short Form-36 [SF-36])., Results: The mean ASQoL score was 7.1 ± 5.7. SF-36 subscales of general health, physical role and bodily pain had the poorest scores. ASQoL was strongly correlated with disease duration, BASDAI, fatigue, BASFI, BASMI, BASRI, MASES, pain and SF-36 subscales (P < 0.001). SF-36 subscales were also strongly correlated with BASDAI and BASFI. Advanced educational status and regular exercise habits positively affected QoL, while smoking negatively affected QoL., Conclusions: In patients with AS, the most significant variables associated with QoL were BASDAI, BASFI, fatigue and pain. ASQoL was noted to be a short, rapid and simple patient-reported outcome (PRO) instrument and strongly correlated with SF-36 subscales.