#2-33E. MRI in AxSpA Non-Responders: Inflammatory Drivers and Clinical Decision Making (RMD Open, 2025)

How do you manage patients with axial spondyloarthritis (axSpA) who continue to experience significant symptoms despite being on conventional or biologic therapy? Current guidelines often hesitate to recommend routine MRI for monitoring disease activity, leaving clinicians uncertain about the persistence of objective inflammation. This large, real-world service evaluation from two tertiary rheumatology centers assessed the utility of repeat MRI scans requested to evaluate treatment non-response in 335 axSpA patients, aiming to clarify the role of imaging in assessing persistent disease activity and its influence on clinical management. The key finding is that nearly half of patients with ongoing symptoms demonstrated active bone marrow edema (BMO) on monitoring MRI, and these inflammatory findings were strongly associated with subsequent treatment escalation. For physicians, this research is crucial as it demonstrates the ability of MRI to distinguish between inflammatory drivers requiring therapy adjustments and non-inflammatory causes (like degenerative changes), providing practical guidance for individualized patient care. However, a critical point to consider is the study's retrospective nature, which means treatment decisions were influenced by the MRI results, limiting the ability to compare long-term outcomes based solely on MRI status.

Citation: Weddell J, Farah A, Shah R, et al. Utility of repeat MRI in assessing treatment non- response in axial spondyloarthritis: data from two large tertiary rheumatology centres. RMD Open. 2025. DOI: 10.1136/rmdopen-2025-005925

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