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A MedPage Today report published Nov. 2 describes why people with spondyloarthritis can still have symptoms after DMARD treatment reduces inflammation. Specialists say pain, structural damage and other health conditions may contribute, while limited objective measures make it difficult to distinguish these causes from active inflammation.
People with spondyloarthritis (SpA) may continue to experience pain and other symptoms even when medication has controlled inflammation, according to a MedPage Today report published Nov. 2. Rheumatologists interviewed for the report said that pain, joint damage and coexisting conditions can contribute to symptoms, making it difficult to know whether a patient needs a different disease-modifying drug or another approach to care.
New medicines can improve symptoms for many patients, but clinical trial response rates are not close to 100%. In trials cited by MedPage Today, 35% to 40% of patients taking filgotinib, a selective Janus kinase inhibitor, achieved an ASAS40 response, compared with 18% to 21% taking placebo. For the anti-IL-17A drug vunakizumab, 65.6% achieved ASAS20, versus 42.5% with placebo. These measures track changes in patient-reported pain, function, overall assessment and inflammation; they do not mean every symptom has disappeared.
Abhijeet Danve, a rheumatologist at Yale School of Medicine, told MedPage Today that residual symptoms are common even after inflammation is adequately treated. He said pain may also arise from nociplastic pain, degenerative disc disease or facet arthritis. Depression and obesity can also affect how patients feel, according to Lianne Gensler of the University of California, San Francisco. These possibilities do not rule out active SpA, but they complicate decisions about changing treatment.
Clinicians lack a straightforward examination or biomarker that reliably identifies inflammation in the spine and sacroiliac joints. Gensler said MRI can help, but it is not specific enough to settle every case and cannot be repeated whenever symptoms arise. The report describes this uncertainty as a challenge for decisions about escalating or switching DMARDs.
When Persistent Pain Does Not Mean Inflammation
The distinction matters because symptoms alone may not show whether a DMARD has failed to control inflammation. If ongoing pain is automatically treated as evidence of active disease, patients may move rapidly between drugs without addressing other causes. Conversely, incorrectly attributing symptoms to damage or pain processing could miss continuing inflammatory activity. The report points to a need for clinicians to assess each patient’s symptoms and objective findings together, rather than treating a patient-reported score as a complete measure of inflammation.
Danve recommended physical therapy and regular exercise for some patients with residual symptoms, alongside medications that may help nociplastic pain. Those options are not substitutes for evaluating possible active disease; treatment choices depend on the individual’s clinical situation. The practical issue for patients is that symptom relief and control of inflammation are related but not identical goals.
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How SpA Treatment Is Evaluated
SpA is a group of conditions involving inflammation in the spine or at entheses, where tendons and ligaments attach to bone. Axial SpA affects the spine and includes radiographic disease, also known as ankylosing spondylitis, and non-radiographic disease. Peripheral SpA can affect other areas, including the heels. Treatment often begins with nonsteroidal anti-inflammatory drugs before clinicians consider targeted therapies.
A 2026 American College of Rheumatology guideline update recommended TNF inhibitors and IL-17 blockers ahead of JAK inhibitors as initial biologic DMARD treatment for ankylosing spondylitis and axial SpA, according to the report. Separately, the Assessment of SpondyloArthritis International Society issued a consensus definition in 2025 for difficult-to-manage axial SpA: inadequate disease control and problematic symptoms, with failure of at least two biologic or targeted synthetic DMARDs. Treatment-refractory disease is a narrower category that also requires objective inflammatory activity and exclusion of non-inflammatory explanations.
“It is common to have persistent symptoms despite treatment of inflammation.”
— Abhijeet Danve, Yale School of Medicine, speaking to MedPage Today
What Symptoms Alone Cannot Show
The report does not establish how often persistent symptoms reflect active inflammation versus pain processing, structural damage or other conditions. Nor does it identify a single test that can reliably separate these explanations for every patient. MRI may contribute evidence, but Gensler cautioned that it is not specific and is not practical to use each time symptoms occur. The available trial response figures also describe groups of participants; they cannot determine why a particular patient continues to feel unwell.
The source material ends mid-sentence while discussing evidence about difficult-to-manage symptoms. It does not provide the rest of that discussion or additional findings, so no further conclusion about those groups can be drawn here.
Clinical Assessment Beyond Drug Switching
For patients with continuing symptoms, the immediate next step described by the specialists is careful assessment of whether there is objective evidence of active inflammation and whether other contributors may be involved. The 2025 consensus definition gives clinicians a shared framework for describing difficult-to-manage axial SpA, while distinguishing it from treatment-refractory disease that requires evidence of inflammation.
The report does not announce a new diagnostic test or treatment recommendation. Further research and clinical guidance will be needed to improve objective monitoring and clarify how best to manage symptoms that persist despite DMARD therapy. For now, treatment decisions remain dependent on individual evaluation rather than symptoms alone.
Key Questions
Can symptoms continue after a DMARD controls inflammation?
Yes. Rheumatologists cited in the report say symptoms can persist because of nociplastic pain, degenerative changes, damage or coexisting conditions, even when inflammation has been treated. Persistent symptoms can also occur alongside active disease, so they need clinical assessment.
Does ongoing pain mean a DMARD has failed?
Not necessarily. The report says patient-reported symptoms do not by themselves establish ongoing inflammation. Clinicians consider the full picture, including objective findings and possible non-inflammatory causes, before deciding whether to change treatment.
What is difficult-to-manage axial spondyloarthritis?
Under the 2025 ASAS consensus definition cited in the report, it involves failure of at least two biologic or targeted synthetic DMARDs, suboptimal disease control, and problematic signs and symptoms perceived by both the patient and rheumatologist.
What can help with residual symptoms?
Danve suggested physical therapy and regular exercise, and mentioned medicines that may help nociplastic pain. These are options to discuss with a clinician; they do not replace evaluation for active inflammation or individualized medical advice.
Source: medpagetoday.com
