To quantify the number and cumulative radiation dose of pelvic and lumbar radiographs obtained before sacroiliac computed tomography (CT) confirmed diagnosis of radiographic axial spondyloarthritis (r-axSpA), and to assess potential dose reduction if CT had been used instead of repeated radiographs. Pelvic and lumbar radiographs performed prior to CT were identified from institutional and national databases. Literature-derived effective dose estimates were applied to calculate minimum- and maximum-bound cumulative radiographic doses per patient. Hypothetical scenarios assumed diagnosis via a single low-dose CT (0.5 mSv) or conventional CT (4-10 mSv). Paired Wilcoxon signed-rank tests compared cumulative X-ray doses with CT benchmarks. A total of 235 radiographs were performed before CT (mean 2.47 per patient, range 0-8). Most patients (77.9%) had ≥2 combined radiographs, often clustered into multiple imaging sessions. Minimum-bound cumulative X-ray dose ranged from 0.00-1.60 mSv (median 0.40 mSv), and maximum dose from 0.20-11.20 mSv (median 2.80 mSv). Under minimum assumptions, radiographic exposure was similar to low-dose CT (p= 0.307), with 10.5% ≥0.5 mSv. Under maximum assumptions, exposure was markedly higher (median +2.30 mSv, p< 0.001; 82.1% ≥0.5 mSv). Compared with a fixed 4.0 mSv conventional CT benchmark, no patients in the minimum scenario and 7 (7.4%) in the maximum scenario exceeded threshold. In CT-confirmed r-axSpA, multiple radiographs are frequently obtained before definitive imaging, adding substantial radiation without improving diagnostic yield, whereas a single appropriately indicated low-dose CT could achieve structural assessment with less redundant exposure.

Axial involvement in psoriatic arthritis (axPsA) is common but is more heterogeneous than classical axial spondyloarthritis (axSpA). Posterior soft-tissue inflammation is a potential cause of back pain in axPsA. Here, we report a case series illustrating this presentation. All cases were newly presented with a diagnosis of psoriatic arthritis (PsA) and inflammatory back pain. Clinical and demographic details were extracted from medical notes and imaging of the spine and sacro-iliac joints was performed according to local protocols. All five patients presented with peripheral symptoms and had inflammatory back pain. All patients had some soft-tissue inflammation of the posterior elements of the spine, usually interspinous ligamentitis. Three patients also had imaging evidence of sacroiliitis and two patients imaging evidence of enthesitis in the vertebral bodies. This report highlights interspinous ligamentitis as a possible cause of inflammatory back pain in axPsA that may be overlooked in MRI reports that focus on the sacroiliac joints and vertebral bodies. This feature may also have implications for treatment options in axPsA.

Time to lift the moratorium on IL-23 inhibitors for axial psoriatic arthritis.

Factors associated with rapid spinal radiographic progression in patients with axial spondyloarthritis: A hospital-based retrospective cohort study with mSASSS scoring using deep learning model.

Gut microbiota analysis revealed unique biomarkers in Ankylosing Spondylitis and Non-radiographic Axial Spondyloarthritis.

Rheumatologist and patient perspectives on axial spondyloarthritis management and treatment satisfaction in Europe.

Abstract Objectives Longstanding, personalised, supervised exercise therapy proved to be (cost)effective for people with rheumatoid arthritis (RA) or axial spondyloarthritis (axSpA) with severe functional limitations. Despite policy support, implementation in routine care is challenging. This study aimed to identify barriers and facilitators to its uptake in clinical practice. Methods We conducted 18 semi-structured interviews with key stakeholders (patients, rheumatologists, physiotherapists, insurers). The Consolidated Framework for Implementation Research (CFIR) guided the interviews. Interview transcripts were analysed in Atlas.ti using direct content analysis, findings were mapped to the CFIR domains. Barriers and facilitators were categorized across three healthcare delivery stages: (self)referral, eligibility assessment, and treatment. Results Barriers and facilitators were identified across all stages. Patients primarily mentioned adherence-related factors, rheumatologists focused on referral pathways, physiotherapists emphasized eligibility assessment and actual provision, and insurers highlighted the extent of use and financial coverage. Cross-cutting barriers included eligibility criteria, limited access to trained physiotherapists, unclear referral processes, and financial uncertainties. Facilitators included strong evidence of effectiveness, consistent messaging, clear information channels, and availability of a training course for physiotherapists to deliver the longstanding exercise therapy. Conclusion Despite policy support, implementing longstanding exercise therapy can be challenging across multiple stakeholder groups and healthcare delivery stages. A coordinated, multi-stakeholder approach is essential to address barriers while utilizing facilitators. Implementation strategies must improve referral processes, clarify eligibility criteria, enhance patient education, and ensure the availability of trained physiotherapists.

Background/Objectives: Interleukin-17A (IL-17A) is a key pathogenic cytokine in autoimmune arthropathies. Current monoclonal antibody inhibitors targeting the IL-17/IL-17RA axis demonstrate clinical efficacy but face significant limitations, including immunogenicity, the loss of therapeutic response, and cold-chain storage. Our study evaluated oligonucleotide aptamers targeting IL-17A and its receptor as an alternative to monoclonal antibodies to suppress an IL-17A-induced inflammatory response in cell models relevant to immunoinflammatory rheumatic diseases. Methods: We examined three aptamers: 2′-F-RNA aptamers Apt21-2 and Apt3-4 specific to IL-17A and DNA aptamer RA10-6 targeting the receptor of IL-17A. Their ability to suppress IL-17A functional activity was assessed in peripheral blood mononuclear cells (PBMCs) from healthy donors and personalized fibroblast-like synoviocytes (FLSs) from patients with axial spondyloarthritis (axSpA) and rheumatoid arthritis (RA). Inhibition was measured by quantifying IL-6 and MMP-13 secretion using ELISA and flow cytometry, using secukinumab as a reference control. Results: In PBMC, all aptamers suppressed IL-17A-stimulated IL-6 secretion and cell proliferation in a concentration-dependent manner (17–200 nM), with a 65–85% efficacy, comparable to that of secukinumab. In axSpA-derived FLS, we observed time-dependent efficacy: At 4 h, all three aptamers suppressed IL-6 to the same extent as secukinumab; at 24 h, RA10-6 maintained high efficacy while Apt21-2 and Apt3-4 showed reduced activity. A combination of receptor-targeting RA10-6 with anti-IL-17A aptamers resulted in synergistic IL-6 suppression. All aptamers reduced MMP-13 to basal levels. RA-derived FLS showed diminished responses to all inhibitors. Conclusions: Aptamers demonstrate high specificity and sustained efficacy in suppressing IL-17A signaling for an in vitro model of spondyloarthritis, with superior performance over antibodies. Disease-dependent differential efficacy in RA FLS reflects heterogeneity consistent with limited clinical anti-IL-17 efficacy in RA. These findings show the strong potential of the studied aptamers as an alternative to monoclonal antibodies for IL-17-associated inflammatory arthropathies, particularly spondyloarthritis.

To evaluate the clinical characteristics, disease burden, and treatment patterns of axial spondyloarthritis (axSpA) using the recently proposed Assessment of Spondyloarthritis International Society (ASAS) definition of difficult-to-manage axSpA (D2M-axSpA). A total of 383 patients with axSpA were enrolled. This multicenter cross-sectional study was conducted in three tertiary care centers, enrolling consecutive axSpA patients from outpatient clinics. Patients were classified as D2M-axSpA based on prior use of biologic or targeted synthetic disease-modifying antirheumatic drugs (b/tsDMARDs) and persistent disease activity based on the ASAS definition. Logistic regression analysis identified factors associated with D2M-axSpA. Among patients, 11.2% met the D2M-axSpA criteria. The cohort was 58.7% male, with a mean age of 43.5 ± 10.5 years. Radiographic axSpA was present in 70.8%, and 69.2% of patients had received biological therapy. D2M-axSpA patients exhibited higher inflammatory markers (ESR, CRP), increased disease activity (BASDAI, ASDAS-CRP), and greater functional impairment (BASFI, ASQoL). Peripheral arthritis (p = 0.001), enthesitis (p = 0.031), smoking history (p = 0.037), and comorbidities (p = 0.020) were significantly more frequent in D2M-axSpA. Among D2M-axSpA patients, 22/383 (5.7%) fulfilled the treatment-refractory criteria. Radiographic findings revealed higher rates of sacroiliac ankylosis, lumbar syndesmophytes, symphysitis, and ischial enthesitis, as well as mSASSS scores. Logistic regression identified anterior uveitis (OR: 4.474, p = 0.007), peripheral arthritis (OR: 2.684, p = 0.021), and comorbidities (OR: 2.878, p = 0.013) as independently associated factors. Findings highlight the clinical and radiographic burden of D2M-axSpA and emphasize the need for optimized treatment strategies, particularly in patients with comorbidities, a history of anterior uveitis or peripheral arthritis, and those with a smoking history.

Difficult to manage (D2M) axial spondyloarthritis (axSpA) is an evolving clinical concept. We aimed to assess the prevalence, predictors and long-term outcomes of D2M axSpA. Prospective single center cohort study of axSpA patients starting targeted agents (01/01/2007 until 28/02/2024). The ASAS criteria were applied to classify D2M. Baseline parameters were assessed as predictors of D2M development by multivariate logistic regression models. To identify comorbidity clusters and their contribution to D2M, a K-means cluster analysis on binary indicators of most prevalent chronic illnesses was performed. Long-term functional evolution and adverse events' rate were compared between D2M and non-D2M. Out of 434 patients, 50 (11.5%) developed D2M disease. Compared to non-D2M, they had higher disease activity at baseline (p = 0.01) and failed to improve at 6 months (p < 0.0001), while dyslipidemia, osteoarthritis and fibromyalgia were more prevalent (p < 0.0001). Independent predictors for developing D2M axSpA were the presence of fibromyalgia (OR 3.55), osteoporosis (OR 5.67) and dyslipidemia (OR 2.70), while two clusters of comorbidities ("chronic pain syndromes" and "metabolic") significantly contributed to D2M (OR 2.52 and OR 3.30; p = 0.010 and 0.013 respectively). During a total follow-up period of 2312 patient-years, D2M patients developed higher functional impairment and had more serious adverse events and hospitalizations (p = 0.016) compared to non-D2M patients. 11.5% of axSpA patients developed D2M disease and showed adverse long-term outcome compared to non-D2M. While D2M patients had at baseline higher disease's burden, comorbidities mostly related to chronic pain syndromes predicted D2M development, supporting their significance for D2M axSpA evolution.

Axial spondyloarthritis (axSpA) is a chronic inflammatory disease characterized by complex pain mechanisms that extend beyond inflammation. Although inflammatory nociceptive pain - primarily mediated by pro-inflammatory cytokines - represents the classic pathway and therapeutic target, many patients continue to experience pain despite suppression of inflammation. This residual pain often reflects non-inflammatory processes, including nociplastic and neuropathic pain. Central sensitization, a key mechanism of nociplastic pain, contributes to pain amplification and poor response to treatment. Fibromyalgia, considered the typical phenotype of nociplastic pain, can co-occur with axSpA and is associated with increased symptom burden and reduced efficacy of anti-inflammatory therapies. Neuropathic pain, albeit less common, can result from structural complications and requires targeted therapeutic approaches. In addition, biological sex differences further influence pain perception and treatment outcomes: female patients report more widespread pain, show higher rates of central sensitization and have a worse response to biologic therapies than male patients. Current treatment paradigms are effective for inflammation-driven symptoms but often fail to address the broader spectrum of pain phenotypes in axSpA. Future work should include the development of biomarkers to differentiate pain mechanisms, the refinement of assessment tools and the evaluation of multimodal therapies that target both inflammation and pain processes. This evolving understanding necessitates a shift from an inflammation-centric to a mechanism-informed approach to pain management in axSpA.

This study (the SpACT study) aimed to investigate the frequency and localisations of different types of spinal new bone formation (NBF) in patients with axial spondyloarthritis (axSpA), psoriatic arthritis (PsA), rheumatoid arthritis (RA) and healthy controls (HCs) using low-dose CT (ldCT). Patients with axSpA, PsA or RA, and HC without a history of chronic back pain were included and underwent ldCT of the entire spine. Three readers blinded to all clinical information, including diagnosis, assessed sagittal and coronal images for NBF: (1) marginal syndesmophytes, (2) non-marginal syndesmophytes and (3) osteophytes. 69 participants (33 females, mean age 51.4 years) were included: AxSpA: 30; PsA: 19; RA: 10; HC: 10. Across all groups, the thoracic spine consistently showed the highest number of NBFs, especially for marginal syndesmophytes and osteophytes. Furthermore, on sagittal images, NBF, regardless of type, occurred predominantly at the anterior vertebral corners. Coronal images showed right-sided dominance of NBFs, particularly osteophytes and non-marginal syndesmophytes, whereas marginal syndesmophytes had an almost equal overall distribution. Both sagittal and coronal reconstructions demonstrated high inter-reader reliability (intraclass correlation coefficient >0.9) for almost all groups for detecting any type of NBF. AxSpA exhibited a distinct NBF pattern characterised by frequent marginal syndesmophytes, particularly in the thoracic spine. In contrast, the most prevalent findings in the other groups were osteophytes, and no consistent NBF pattern was observed to distinguish the groups from each other. Further studies, especially longitudinal assessments using ldCT or equally bone-sensitive imaging methods, are needed to further increase our understanding of NBF patterns.

This study was aimed at determining the prevalence of difficult-to-treat (D2T) axial spondyloarthritis (axSpA) and identifying main associated factors for D2T axSpA. This multicenter observational cross-sectional study included axSpA patients from the BioSTaR (Biological and Targeted Synthetic Disease-Modifying Antirheumatic Drugs Registry) from February 1, 2019, to January 1, 2025. Data from 1800 axSpA patients who have previously used or are currently using at least one biologic/targeted synthetic disease-modifying antirheumatic drug were analyzed. Patient data included demographic characteristics, body mass index (BMI), marital status, smoking and alcohol use, family history of SpA, and presence of comorbidities. The parameters related to SpA such as disease duration, type of axSpA (radiographic/non-radiographic), HLA-B27 status, the presence of extra-musculoskeletal manifestations (uveitis, psoriasis, and inflammatory bowel disease), arthritis, enthesitis, and dactylitis were also recorded. Comorbidities including hypertension, cardiovascular disease, diabetes, obesity, and hyperlipidemia were recorded, and Charlson Index scores were evaluated. Maastricht Ankylosing Spondylitis Enthesitis Score (MASES) and disease activity in means of Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) and Ankylosing Spondylitis Disease Activity Score with C-reactive protein (ASDAS-CRP) were also recorded. All medication history and currently used medications for axSpA and other diseases were noted. D2T and non-D2T axSpA patients were classified according to the suggested extrapolated definition. Of the 1800 axSpA patients recorded in the BioSTaR database, 204 (11.3%) were classified as D2T axSpA. Data of these patients were compared to the data from 1596 non-D2T axSpA patients. Disease duration was longer in D2T patients (p = 0.025). The presence of radiographic disease was more frequent in the D2T group (p = 0.047). In means of MASES and ASDAS-CRP, higher scores were recorded in the D2T group (both p < 0.001). Enthesitis and psoriasis were more frequent in the D2T group (p = 0.002 and p = 0.006). Regarding comorbidities, hypertension and cardiovascular diseases were more frequent in the D2T group (p < 0.001 and p = 0.009). The risk of D2T axSpA increased 2.37-fold with the presence of r-axSpA (p = 0.018), 1.92-fold with the presence of hypertension (p = 0.006), 2.12-fold with the presence of obesity (p = 0.024), and 3.63-fold with the presence of psoriasis (p = 0.004). Every 1-point increase in MASES increased D2T risk 1.08-fold (p = 0.017), and every 1-point increase in ASDAS-CRP increased D2T risk 1.62-fold (p < 0.001). In conclusion, 11.3% of patients with axSpA met the proposed criteria for D2T axSpA. This subgroup was characterized by longer disease duration, higher frequency of r-axSpA, enthesitis, and psoriasis, as well as elevated MASES, CRP, ASDAS-CRP, and BASDAI scores. Hypertension and cardiovascular comorbidities were also significantly more prevalent among D2T patients. These parameters represent potential contributors to treatment complexity and should be carefully considered in therapeutic decision-making. In cases of suboptimal treatment response, reassessment and optimal management of comorbidities are essential, as comorbid conditions can increase disease burden and diminish therapeutic efficacy. Comprehensive care for axSpA should therefore include targeted management of accompanying comorbidities in parallel with disease-specific therapy. Monitoring blood pressure, optimizing body weight, and encouraging smoking cessation are particularly important. Additionally, concomitant rheumatic diseases such as psoriasis, uveitis, or inflammatory bowel disease should be actively evaluated and treated, given their association with more severe disease and reduced treatment response. Key Points • Prospectively collected data of 1800 axial spondyloarthritis patients were assessed for this cross-sectional study. • 11.3% of axial spondyloarthritis patients were identified as difficult-to-treat. • Longer disease duration and presence of radiographic axial spondyloarthritis, enthesitis, and psoriasis are more prevalent in difficult-to-treat axial spondyloarthritis patients. • Factors and comorbidities complicating axial spondyloarthritis treatment should be considered in treatment plans.

To develop machine learning (ML) models to predict the probability at baseline of achieving low disease activity (LDA) and high health-related quality of life (HRQOL) in patients with psoriatic arthritis (PsA) or axial spondyloarthritis (axSpA) treated with secukinumab (SEC). AQUILA is an ongoing multicenter, prospective, noninterventional study assessing the effectiveness and safety of SEC in patients with active PsA or axSpA in Germany. Data from 1961 participants were used to develop ML models for predicting treatment outcomes. We investigated baseline prediction of achieving LDA and high HRQOL at week 16 using binary ML algorithms, identifying main predictors for LDA and high HRQOL and their direction of influence. In addition, explainable artificial intelligence (XAI) estimated the importance and impact of each predictor based on how it affected the change in individual patient predictions. In PsA, the main LDA predictors were patient global assessment, physician global assessment, pretreatment with biologic disease-modifying antirheumatic drugs (bDMARDs), tender joint count (TJC), and age; high HRQOL predictors were PsA Impact of Disease, Beck Depression Inventory (BDI), height, TJC, and BMI (kg/m2). In axSpA, the main LDA predictors were Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), pretreatment with bDMARDs, C-reactive protein, Assessment of SpondyloArthritis international Society Health Index (ASAS HI), and height; high HRQOL predictors were ASAS HI, BDI, BMI, height, and age. XAI provides significant value by enabling explanations of individual patient predictions and their visualizations. This modeling approach may help in the development of a clinical decision support system for patient management.

Psoriatic arthritis and axial spondyloarthritis belong to a group of related inflammatory conditions known as spondyloarthritis (SpA), each with several musculoskeletal and extra-musculoskeletal manifestations. Disease onset can be insidious, and symptoms affect patient quality of life in subtle but impactful ways, requiring careful discernment to ensure proper diagnosis and management. Heterogeneity of disease manifestations often leads to under-recognition and delayed diagnosis, resulting in suboptimal disease management and clinical outcomes. In the United States (US), advanced practice providers (APPs), including nurse practitioners and physician assistants, have opportunities to contribute meaningfully to the management of patients with SpA. The role of APPs in SpA management is multifaceted and includes performing patient examinations, ordering and interpreting diagnostic tests, providing differential diagnoses, determining and executing treatment plans with patient input, evaluating treatment efficacy and safety outcomes. Furthermore, APPs enhance care by decreasing time to clinical visits and educating patients on disease awareness and available treatments. Having more time than rheumatologists to spend with patients is a key benefit for APPs in managing patients with SpA and ultimately results in a deeper emotional connection and understanding of the individual burdens and disease manifestations faced by patients with SpA. The goals of this narrative review are to provide a brief overview of SpA, highlight the value of APPs in rheumatology practice in the US by reviewing recent literature, and offer expert commentary both from the perspectives of the rheumatologist and APP on the importance of these practitioners in meeting the unique needs of patients with SpA.

Axial spondyloarthritis (axSpA) imposes a multidimensional burden that is not fully explained by inflammation. Central sensitization (CS), pain catastrophizing (PC), and sleep disturbance may amplify symptoms and worsen outcomes. This study aimed to assess the prevalence and impact of CS, PC, and sleep disturbances in axSpA patients and their associations with disease activity, function, and quality of life compared with controls. This cross-sectional study included adults with axSpA (ASAS 2009) and healthy controls recruited from a tertiary clinic (April 2024-April 2025). The assessments included demographics; CSI, PCS, JSS, fibromyalgia (ACR-2016), fibromyalgianess (WPI + SSS); and axSpA outcomes (BASDAI, ASDAS, BASFI, BASMI, ASQoL, CRP, and MASES). Statistical analyses included group comparisons, correlations, and multivariable regressions. We enrolled 100 axSpA patients and 50 controls. The median scores were greater in the axSpA patients for the CSI (42 vs. 28), PCS (32 vs. 12.5), and JSS (12 vs. 6) (all p < 0.001). The prevalence was greater for CS (59% vs. 20%), PC (53% vs. 18%), and fibromyalgia (43% vs. 18%). The WPI was strongly correlated with the SSS (r = 0.92). In the axSpA patients, the CSI was correlated with the BASDAI (r = 0.58), ASDAS (r = 0.43), BASFI (r = 0.45), and ASQoL (r = 0.68) (all p ≤ 0.001). The PCS and JSS are also correlated with disease activity, disease function, and ASQoL. Independent predictors were CSI-female sex, higher SSS, and worse ASQoL; PCS-ASQoL; JSS-higher SSS and arthritis, with lower scores in patients on TNF inhibitors or pain-modulating therapy. CS, PC, sleep disturbance, and FM/FMness are highly prevalent in axSpA patients and are independently associated with worse outcomes. Incorporating nociplastic and psychosocial dimensions into assessment and care is crucial to reduce disease burden.

Sclerostin regulates bone formation via Wnt/β-catenin signaling inhibition and contributes to intestinal epithelial homeostasis. Circulating sclerostin levels are reduced in axial spondyloarthritis (axSpA) and correlate with structural damage. LRP5, a receptor inhibited by sclerostin, also controls bone formation by regulating gut-derived serotonin synthesis, indicating a hormonal link between the intestine and bone. We hypothesized that gut dysbiosis-dependent downregulation of sclerostin alters intestinal serotonin production, contributing to disease-specific gut-bone signaling in axSpA. We quantified sclerostin and the serotonin-synthesizing enzyme TPH1 by qRT-PCR, and assessed serotonin protein levels by immunohistochemistry in ileal biopsies from treatment-naïve axSpA patients (n = 25) and healthy controls (n = 20), alongside measurement of circulating serotonin in peripheral blood platelets. We evaluated TPH1 expression in BON-1 cells following sclerostin and WNT3a treatment. Findings were validated in HLA-B27 transgenic rats, SKG mice, and Sost⁻/⁻ mice. Serotonin receptor expression in spinal entheseal cells was analyzed by RT-PCR, and LPS-induced HTR2B modulation was examined. In healthy controls, sclerostin modulated TPH1 expression and serotonin synthesis in enterochromaffin cells. In axSpA patients, intestinal sclerostin downregulation coincided with increased numbers of serotonin-positive enterochromaffin cells and elevated platelet serotonin levels. Broad-spectrum antibiotics restored intestinal sclerostin expression and normalized serotonin production in HLA-B27 transgenic rats. Sost⁻/⁻ mice exhibited increased intestinal Tph1 expression, while SKG mice showed reduced sclerostin and elevated Tph1 following curdlan-induced colitis-an effect dependent on the presence of intestinal microbiota. Human spinal entheses expressed HTR1B, HTR2A, and HTR2B, with LPS selectively inducing HTR2B expression. We identify a gut microbiota-dependent sclerostin-serotonin axis that regulates serotonin production and may contribute to gut-bone pathology in axSpA. These findings reveal novel mechanisms linking gut dysbiosis to bone disease and suggest potential therapeutic targets within the gut-bone-immune axis.

Sex differences in pain-related biopsychosocial assessments in patients with axial spondyloarthritis.

Purpose Rheumatoid arthritis (RA) and axial spondyloarthritis (axSpA) are chronic inflammatory diseases that often lead to reduced work ability. This study explored participants’ perspectives on their experiences with a physiotherapist (PT)-led, vocational intervention to improve work ability. Material and methods A qualitative process evaluation, integrated into the Physiotherapy WORKs randomized controlled trial, compared a PT-led vocational intervention to usual care in people with RA or axSpA and reduced work ability. Semi-structured interviews with 10 participants were conducted using a standardized interview guide, recorded, transcribed verbatim, and analyzed using thematic analysis. Results Three themes emerged. First, perceived effects included a) enhanced awareness or symptoms and balance between capacity and load; b) improved self-management and c) better physical functioning. Second, facilitators included a) personalized approach, b) trust in physiotherapists’ expertise, c) comprehensive, work focused content and d) optionality of treatment modalities. Third, a mismatch was perceived between intervention and the participants’ perceived severity of work-related limitations. Conclusion Employed people with RA or axSpA valued the intervention’s personalized approach and the professional expertise of the PT. However, better alignment between the intervention and severity of work-related limitations is needed. These findings offer valuable insights for improving the content and implementation of vocational interventions.

To establish a UK-specific consensus on improving standards of care for patients with PsA and axial SpA through patient empowerment, education, access and optimal treatment approaches. A modified Delphi methodology was employed. A steering group of UK rheumatologists and pharmacists developed 56 consensus statements across four domains: patient empowerment, patient and healthcare professional (HCP) knowledge, access to healthcare and treatment principles. These statements were tested with a panel of 100 UK rheumatologists using a 4-point Likert scale. Consensus was predefined as ≥75% agreement. Consensus was achieved for 98% (55/56) of statements; 93% (52/56) reached strong consensus (≥90%). Statements supported embedding patient empowerment tools (e.g. patient-reported outcome measures, patient activation measures), implementing patient-initiated follow-up and ensuring shared decision-making. Respondents strongly endorsed multidisciplinary care, tailored educational resources, psychological support and timely access to physiotherapy and biologics. Treatment decisions should prioritise clinical need and patient goals rather than cost alone. This UK Delphi consensus highlights expert agreement that best practice care for PsA and axial SpA should centre on patient empowerment, supported by multidisciplinary teams, education and equitable access to treatments. Implementing personalised, holistic care models has the potential to improve patient outcomes and reduce healthcare burden. Further research should validate these recommendations with patients and explore strategies for their integration into National Health Service practice.