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A MedPage Today report published November 2, 2026, examines why people with spondyloarthritis can still have symptoms after DMARD treatment. Rheumatologists caution that persistent pain does not always mean inflammation remains active, and that distinguishing causes is difficult because available assessments have limitations.
People with spondyloarthritis (SpA) may continue to experience pain and other symptoms even when medication has reduced inflammation, according to a November 2 report by MedPage Today. Rheumatologists interviewed for the report said residual symptoms can arise from causes other than active disease, making treatment decisions difficult and raising concern that symptoms alone may prompt unnecessary changes to disease-modifying antirheumatic drugs (DMARDs).
Clinical trial results help show why symptom-free outcomes are not the norm. In trials cited by MedPage Today, 35% to 40% of participants receiving the selective JAK inhibitor filgotinib achieved an ASAS40 response, compared with 18% to 21% receiving placebo. In a separate trial, 65.6% of participants receiving the anti-IL-17A drug vunakizumab achieved ASAS20, compared with 42.5% receiving placebo. These are different response thresholds and trials; the figures do not establish how an individual patient will respond.
ASAS20 and ASAS40 are based on patient assessments of disease, spinal pain, function and inflammation. ASAS40 requires at least a 40% improvement, plus specified improvement across three of four domains; ASAS20 uses a 20% threshold and its own criteria. The report notes that established axSpA DMARD trials commonly produce ASAS40 responses in roughly 40% to 55% of participants, indicating that many people do not meet that response benchmark even when a treatment is considered successful.
MedPage Today cited nociplastic pain, structural damage, degenerative disc disease, facet arthritis and conditions such as depression or obesity as possible contributors to ongoing symptoms. These causes can overlap with inflammatory disease. The report also described filgotinib and vunakizumab trial findings as part of continuing drug development; they do not, on their own, show that either medicine is approved for every SpA subtype or appropriate for every patient.
Why Persistent Pain Can Mislead
The distinction matters because pain is not a direct measure of inflammation. If symptoms continue, clinicians and patients must weigh whether inflammation is still active, whether there is lasting damage, or whether another pain mechanism or health condition is contributing. A treatment change based only on symptoms may expose a patient to a different drug without addressing the actual source of discomfort.
At the same time, assuming symptoms are non-inflammatory could miss ongoing disease in a person who needs a different treatment. The report presents this as a clinical assessment problem, not a reason to discount patients’ experiences. It points to the need to interpret symptoms alongside examination, imaging where appropriate, and the broader clinical picture.
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Assessing Axial SpA Activity
SpA is a group of conditions involving inflammation in the spine and/or entheses, where tendons and ligaments attach to bone. Axial SpA affects the spine and includes radiographic disease, also called ankylosing spondylitis, and non-radiographic disease. Peripheral SpA can affect other areas, including the heels. Treatment may begin with nonsteroidal anti-inflammatory drugs before biologic or other targeted DMARDs are considered.
The report says a 2026 American College of Rheumatology guideline update favored tumor necrosis factor inhibitors and IL-17 blockers over JAK inhibitors as initial biologic DMARD treatment for ankylosing spondylitis and axial SpA. It also describes a 2025 Assessment of SpondyloArthritis International Society consensus definition of difficult-to-manage axial SpA: failure of at least two biologic or targeted synthetic DMARDs, suboptimal disease control, and problematic symptoms recognized by both patient and rheumatologist. Treatment-refractory disease is a narrower subset requiring objective signs of inflammation and exclusion of non-inflammatory explanations.
“It is common to have persistent symptoms despite treatment of inflammation.”
— Abhijeet Danve, MD, MHS, Yale School of Medicine, as quoted by MedPage Today
Where Inflammation Remains Hard to See
The report describes a key limitation: axial joints do not have a physical examination finding that clearly confirms inflammation, while MRI is not fully specific and is not practical for every symptom flare. It also says there are no specific monitoring biomarkers that reliably separate inflammatory pain from pain related to degeneration. The source does not provide a single test or decision rule that can settle the cause of symptoms in all patients.
The trial response figures are group results, not evidence that a particular person’s symptoms are inflammatory or non-inflammatory. The report also does not establish how often residual symptoms stem from each possible cause, or whether the newer drugs discussed will change long-term outcomes. Individual assessment and treatment decisions remain matters for patients and their clinicians.
How Clinicians May Respond
For persistent symptoms, the report describes assessing for objective inflammatory activity and considering other contributors before changing DMARDs. Danve suggested physical therapy and regular exercise for some patients, and said medicines such as gabapentin, selective serotonin reuptake inhibitors and muscle relaxants may be considered for nociplastic pain. These options are not appropriate for everyone; medication choices should be discussed with a clinician who can account for a patient’s health and other treatments.
The ASAS difficult-to-manage definition offers clinicians and researchers shared criteria for describing inadequate response, while its distinction between difficult-to-manage and treatment-refractory disease keeps objective inflammation central to the latter. The report does not identify a new clinical guideline or a forthcoming decision date. The next step for individual patients is a clinical review of symptoms, disease activity and possible non-inflammatory causes rather than assuming that persistent pain alone proves a DMARD has failed.
Key Questions
Do symptoms that persist on a DMARD mean inflammation is still active?
Not necessarily. The MedPage Today report says persistent symptoms may also relate to structural damage, nociplastic pain, degenerative conditions or comorbidities. A clinician must assess the person’s situation rather than infer active inflammation from symptoms alone.
What do ASAS20 and ASAS40 measure?
They are response criteria based on patient-reported assessments of disease, spinal pain, function and inflammation. ASAS40 uses a 40% improvement threshold and ASAS20 a 20% threshold, with additional criteria for improvement across domains.
Why is it difficult to confirm inflammation in axial SpA?
According to rheumatologists quoted in the report, there is no physical examination finding that clearly shows inflammation in the axial joints. MRI can help but is not specific, and the report says it cannot be used every time symptoms occur.
What does difficult-to-manage axial SpA mean?
The 2025 ASAS consensus definition cited in the report includes failure of at least two biologic or targeted synthetic DMARDs, suboptimal disease control, and problematic symptoms perceived by both the patient and rheumatologist. Treatment-refractory disease is a subset that also requires objective inflammatory activity and exclusion of non-inflammatory causes.
Source: medpagetoday.com
