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Rheumatology from BMJ Journals

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Contents

RMD Open Sustaining remission in rheumatoid arthritis: the role of clinical deep remission and its implications for drug tapering Development and validation of a new ultrasound score (SONAR-7) for synovitis in psoriatic arthritis and axial spondyloarthritis Lupus Science & Medicine® Efficacy and safety of anifrolumab in patients with systemic lupus erythematosus without prior immunosuppressant use: post hoc analysis of phase 3 TULIP- 1 and TULIP- 2 trials Measurements of urinary biomarkers at 2 years following a lupus nephritis flare are associated with subsequent renal outcomes Elevated serum brain injury markers are associated with disease activity, proinflammatory cytokine levels and cognitive dysfunction in adolescents with childhood-onset SLE

The BMJ Therapeutic advances in rheumatoid arthritis

BMJ Open Efficacy and safety of microbiota-targeted therapeutics in autoimmune and inflammatory rheumatic diseases: protocol for a systematic review and meta-analysis of randomised controlled trials

Rheumatoid arthritis

ORIGINAL RESEARCH Sustaining remission in rheumatoid arthritis: the role of clinical deep remission and its implications for drug tapering

Haihui Li ‍ ‍, Mengyan Zhou, Huaqun Zhu ‍ ‍, Chun Li, Jianping Guo, Yuan Jia, Ru Li

To cite: Li H, Zhou M, Zhu H, et al . Sustaining remission in rheumatoid arthritis: the role of clinical deep remission and its implications for drug tapering. RMD Open 2026; 12 :e006387. doi:10.1136/ rmdopen-2025-006387

ABSTRACT Objective While sustained remission is the treatment goal for rheumatoid arthritis (RA), its long-term remission remains challenging. This real-world study aimed to assess the role of clinical deep remission (CliDR) in sustained remission and the risk of relapse, as well as its interaction with drug tapering. Methods Of the 541 patients enrolled in the cohort, 145 who achieved a Disease Activity Score in 28 joints using C reactive protein (CRP) remission with 5 years of follow-up after remission were included in this study. Participants were stratified by CliDR status (defined as no tender/ swollen joints with normal CRP/erythrocyte sedimentation rate). Kaplan-Meier analysis was used to compare sustained remission rates. Multivariable Cox regression with time-dependent covariates was performed to identify independent predictors and to assess the interaction between CliDR and drug tapering. Results The sustained remission rate declined over time but was significantly higher in the CliDR group (62.5%; 95% CI 45.3% to 77.1%) than the non-CliDR group (38.1%; 95% CI 29.6% to 47.3%) at 5 years (p=0.014). In the non-CliDR group, tapering was associated with an 8.47-fold increase in the hazard of relapse (HR=8.47, 95% CI 5.01 to 14.32, p<0.001). The interaction between group and tapering was statistically significant (HR=0.26, 95% CI 0.07 to 0.98, p=0.046), indicating that the effect of tapering on relapse risk was significantly attenuated in the CliDR group compared with the non-CliDR group. Conclusions Our findings suggest that achieving CliDR is associated with significantly higher sustained remission rates in RA and that the safety of treatment tapering is contingent on prior achievement of CliDR. INTRODUCTION Rheumatoid arthritis (RA) is a chronic, systemic autoimmune disease characterised by erosive polyarthritis. The treatment strategy aims to minimise long-term joint structural damage and preserve physical function in patients with RA, with the primary objective of achieving sustained clinical remission. 1 The

sustained remission rate of RA remains low, especially during the drug tapering process. Even if patients have maintained remission for over a year, there is still a high recurrence rate. 2 3 Residual joint inflammation is a critical obstacle to patients maintaining long-term remission. 4 The definition of remission in RA is clinically challenging, as different remission criteria allow for varying degrees of inflammation. The Simpli- fied Disease Activity Index (SDAI) is the sum of five components: 28-joint tender joint count (TJC28), 28-joint swollen joint count (SJC28), patient global assessment (0–10 cm), physician global assessment (0–10 cm) and C reactive protein (CRP) ⇒ These findings support the integration of CliDR as- sessment into routine clinical practice, which may guide more personalised and safer treatment de- escalation strategies. The results could also inform future guidelines on remission maintenance and drug reduction in RA. WHAT IS ALREADY KNOWN ON THIS TOPIC ⇒ Achieving sustained remission is a key treatment goal in rheumatoid arthritis (RA), but it remains unclear whether clinical deep remission (CliDR) in- fluences sustained disease control and successful drug reduction. WHAT THIS STUDY ADDS ⇒ This study demonstrates that patients with RA who achieve CliDR are significantly more likely to main- tain sustained remission and are less prone to flare during drug tapering. CliDR was associated with a lower risk of relapse, independent of conventional risk factors. HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

HL and MZ contributed equally.

Received 25 September 2025 Accepted 20 March 2026

Department of Rheumatology and Immunology, Beijing Key Laboratory for Rheumatism Mechanism and Immune Diagnosis, Peking University People’s Hospital, Beijing, China permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ Group. © Author(s) (or their employer(s)) 2026. Re-use

Correspondence to Professor Ru Li; liru@pkuph.edu.cn

Professor Yuan Jia; jiayuan1023@sina.com

Li H, et al . RMD Open 2026; 12 :e006387. doi:10.1136/rmdopen-2025-006387

RMD Open

(mg/dL). The Clinical Disease Activity Index (CDAI) employs the same four clinical variables but omits CRP. The SDAI and CDAI scoring systems incorporate a multidimensional compensation framework where elevated joint counts (up to three swollen or tender joints in SDAI remission ( ≤ 3.3) and two swollen or tender joints in CDAI remission ( ≤ 2.8)) may be offset by improvements in patient-reported outcomes (PROs) and normalised acute-phase reactants, resulting in maintained classification within the remission range. 5 6 Boolean remission criteria defined by the American College of Rheumatology (ACR) and the European Alli- ance of Associations for Rheumatology (EULAR), while requiring stricter thresholds (serum CRP level ≤ 1 mg/dL and patient global assessment ≤ 2/10), tolerate residual synovitis with a maximum allowable count of 1 swollen joint out of SJC28 and 1 tender joint out of TJC28 for remission classification. 7 Eliminating the residual inflam- matory lesions to achieve ‘true’ clinical remission may lead to better long-term remission. Previously, we defined clinical deep remission (CliDR) as a state characterised by the absence of tender or swollen joints, alongside normal levels of CRP and erythrocyte sedimentation rate (ESR), indicating minimisation of residual inflammation. 8 9 In this study, we present the first real-world evidence that achieving CliDR predicts both sustained remission and future relapse and enables safer drug tapering in patients with RA.

to insufficient follow-up, defined as having fewer than two DAS28-CRP assessments per year during the post- remission follow-up period. Ultimately, 145 patients who achieved DAS28-CRP remission and satisfied the above inclusion criteria were analysed. Among these, 32 patients met the criteria for CliDR. A detailed flow of participant selection is shown in figure 1. Data collection Baseline was defined as the time of initial DAS28-CRP remission attainment. Demographic data of the patients at baseline were collected, including gender, age, disease duration, smoking status and family history of RA. During the 5-year follow-up after remis- sion, longitudinal clinical variables were systematically recorded from patients’ medical records at each visit, encompassing TJC28, SJC28, extra-articular manifes- tations, comorbidities, key laboratory indicators such as CRP, ESR, rheumatoid factor (RF) and anti-CCP antibodies. Additionally, detailed medication records were obtained, including DMARDs, corticosteroids and treatment adjustments. All variables included in the analysis had no missing data. The final dataset was complete for all baseline covariates and outcomes, with no imputation performed. Outcome measure and definition CliDR is defined as having no tender or swollen joints based on 28 joints with normal CRP and ESR levels. The normal range for CRP is defined as below the upper limit of normal, that is, 0–10 mg/L. The reference range for ESR is 0–15mm/hour in men and 0–20mm/hour in women. Remission according to the DAS28-CRP is defined as a score of DAS28-CRP<2.6, and relapse was defined as an increase in DAS28-CRP of >0.6 from the baseline value and DAS28-CRP >2.6 at any scheduled follow-up visit. 10 Recur- rent event refers to each investigator-reported relapse after the initial remission; event density denotes the average number of relapses per patient-year of follow-up. Sustained remission was defined as DAS28-CRP<2.6 documented at every visit for a minimum of six consec- utive months without any interim increase ≥ 0.6 units or escalation of DMARD therapy. Here, we compare the capacity of CliDR versus DAS28-CRP remission criteria to predict both sustained remission and subsequent relapse in patients with RA. Drug tapering was defined as dose reduction/discontinuation occurring at any point during follow-up. Statistical analysis All analyses were conducted using SPSS Statistics V.25.0. Categorical variables are expressed as frequencies (percentages), whereas continuous variables are presented as mean±SD. Between-group comparisons were conducted using the following methods: for continuous variables, the independent Student’s t-test was applied for normally distributed data and the Mann-Whitney U test was used

METHODS Patients

The observational cohort included a total of 541 patients with RA from the department of rheumatology and immunology at Peking University People’s Hospital. The enrolled patients were predominantly anti-cyclic citrul- linated peptide (anti-CCP) antibody positive and were treated with conventional synthetic disease-modifying antirheumatic drugs (csDMARDs). The patients enrolled from January 2012 to December 2012, and the follow-up is ongoing. For this study, data up to January 2024 were analysed. Patients included in the analysis must meet the following inclusion criteria: (1) achievement of Disease Activity Score in 28 joints using C reactive protein (DAS28-CRP) remission at any visit; (2) a minimum of 5 years of continuous follow-up after the onset of remis- sion; (3) at least two DAS28-CRP assessments per year during this post-remission follow-up period. All patients met the 1987 ACR classification criteria. To ensure a uniform 5-year post-remission follow-up period for analysis, we established a data lock-in point of December 2018. First, patients lost to follow-up prior to this date (n=49) were excluded due to insufficient data. Furthermore, patients who had not achieved clin- ical remission by this cut-off (n=339) were excluded, as they could not provide information on sustained remis- sion over the 5-year period of interest. Additionally, eight patients who attained remission were excluded due

Li H, et al . RMD Open 2026; 12 :e006387. doi:10.1136/rmdopen-2025-006387

Rheumatoid arthritis

RA patients in the initial cohort (n=541)

Excluded (n=388): 1. Lost to follow-up before Dec 2018ͧ n=49ͨ 2. Did not achieve DAS28- CRP remission before Dec 2018ͧ n=339ͨ Excluded (n=8): having fewer than two DAS28-CRP assessments per year

DAS28-CRP remission (n=153)

Patients included in the final analysis (n=145)

Clinical Deep Remission(n=32)

non-Clinical Deep Remission(n=113)

Sustained remission(n=20)

Sustained remission(n=43)

Relapse(n=12)

Relapse(n=70)

Figure 1 Flow diagram of the selection of the participants. DAS28-CRP, Disease Activity Score in 28 joints using C reactive protein; RA, rheumatoid arthritis.

for data with non-normal distribution; for categorical vari- ables, the χ 2 test was performed, and Fisher’s exact test was employed when cell counts were less than 5. Survival analyses included Kaplan-Meier curves to esti- mate cumulative remission rates, with between-group differences assessed via log-rank test. Cox proportional hazards regression models were employed to assess the impact of various factors on disease relapse. We conducted univariate Cox regression analyses with the following candidate variables: group, tapering status, sex, age, disease duration, smoking status, family history of RA, RF titre, anti-CCP titre, comorbidities and extra- articular manifestations. In the univariable analysis, each candidate variable was examined individually. Variables with a p value <0.1 in the univariable analysis were consid- ered for inclusion in the multivariable model. Because drug tapering occurred at different time points during follow-up, it was modelled as a time-dependent covariate. Specifically, a time-dependent variable, tapering status , was defined as I (t ≥ time of tapering) and included in the Cox model to account for its dynamic effect on relapse risk. This variable took the value 0 before tapering initiation and 1 from the exact time of tapering onward.

Patients who never tapered were assigned a tapering time exceeding their last follow-up. The multivariable Cox model was constructed to eval- uate the following prespecified predictors: group effect (CliDR vs non-CliDR) during periods without tapering, the effect of tapering within the non-CliDR group and their interaction term (CliDR×tapering status), along with family history of rheumatic disease (yes vs no), RF titre (continuous, per 1-unit increase) and comorbidities (yes vs no). The interaction term was included to formally test whether the effect of tapering on relapse risk differed between the CliDR and non-CliDR groups. For all categorical variables, the reference category was the absence of the characteristic (eg, no, absent). Contin- uous variables (RF titre) were modelled as linear terms, with HRs corresponding to a 1-unit increase. Results are presented as HRs with 95% CIs. The propor- tional hazards assumption was assessed using tests based on Schoenfeld residuals. For any variable violating this assumption, additional analyses incorporating a time– covariate interaction term or using stratified Cox models were performed.

Li H, et al . RMD Open 2026; 12 :e006387. doi:10.1136/rmdopen-2025-006387

RMD Open

All statistical tests were two-sided, and a p value <0.05 was considered statistically significant.

45.3% to 77.1%) compared with the non-CliDR group (38.1%; 95% CI 29.6% to 47.3%) (p=0.014, figure 2A). The log-rank test revealed a significant difference in remission duration between the two groups ( χ 2=4.675, p=0.031, figure 2B), indicating that patients in the CliDR group experienced a more sustained remission over the 5-year follow-up. Mean sustained remission duration was 44.41 (95% CI 37.07 to 51.75) months for patients in the CliDR group and 38.16 (95% CI 34.15 to 42.17) months for non-CliDR. Because the Kaplan-Meier curves suggested a poten- tial crossing of the survival functions at 5 months, we further examined whether the group effect varied over time by fitting an extended Cox model that included a time-dependent interaction term between group and a dichotomised time covariate split at 5 months (group×I(t>5 months)). This approach tests whether the HR for the group differs before versus after the 5-month cut-off. The interaction term was not statis- tically significant (HR for T_COV_=0.564, 95% CI 0.058 to 5.530, p=0.623), indicating no evidence that the group effect changed over time. Therefore, the proportional hazards assumption was deemed accept- able, and the group effect was considered constant across the entire follow-up period in the final model. During the post-remission follow-up period, the CliDR group experienced 37 recurrence events among 32 patients who developed recurrences. The recur- rence patterns showed that eight patients had single episodes, three patients experienced two recurrences and one patient had three recurrent episodes. The non-CliDR group recorded 80 relapse events occurring in 70 patients. Of these, 60 patients (85.7%) had single relapses, while 10 patients (14.3%) experienced two recurrent episodes. Comparative analysis revealed signifi- cantly lower recurrence rates in the CliDR group versus the non-CliDR group, both in terms of patient propor- tion (37.5% vs 69.1%; p=0.014) and event density (45.0% vs 69.0%; p=0.037). CliDR status modifies the association between drug tapering and relapse risk As shown in table 2, univariable and multivariable Cox proportional hazards models were used to assess factors associated with the outcome. In univariable analyses, vari- ables with a p value <0.10 were considered candidates for the multivariable model. These included group (HR=0.53, 95% CI 0.29 to 0.98, p=0.040), tapering status (HR=4.42, 95% CI 2.78 to 7.02, p<0.001), family history (HR=2.18, 95% CI 1.09 to 4.37, p=0.028), RF titre(HR=1.00, 95% CI 1.00 to 1.001, p=0.075) and comorbidities (HR=0.53, 95% CI 0.33 to 0.87, p=0.012). Multivariable analysis revealed that the effect of tapering differed significantly between the CliDR and non-CliDR groups (interaction HR=0.26, 95% CI 0.07 to 0.98; p=0.046). In the non-CliDR group, tapering was associated with a markedly increased hazard of the outcome (HR=8.47, 95% CI 5.01 to 14.32; p<0.001). In

RESULTS Demographic and clinical characteristics of patients with CliDR or non-CliDR 145 eligible patients were included in the study. The CliDR group included 32 patients, of whom 84.4% were female, with a mean±SD age of 56±13 years. The non- CliDR group comprised 113 patients, with 88.5% being female and a mean±SD age of 54±14 years. No significant differences were observed in age, sex, disease duration, smoking status and family history (p>0.05). Compared with the non-CliDR group, the CliDR group had a significantly less TJC28 (0±0 vs 0.5±0.9, p<0.001), less SJC28 (0±0 vs 0.5±1.2, p<0.001), lower scores of DAS28-CRP (1.6±0.2 vs 2.1±0.3, p<0.001), lower ESR (9.9±4.4 vs 29.2±18.9 mm/hour, p<0.001), lower CRP (2.8±2.1 vs 6.3±6.7 mg/L, p<0.001) and lower proportions of RF positivity (56.3 vs 77.0%, p=0.02). No significant differences were observed in the proportions of anti-CCP positivity. Patients with RA of these two groups had similar frequencies of extra- articular manifestations and comorbidities. At baseline, when DAS28-CRP remission was achieved, the use of combination DMARD therapy was compa- rable between the CliDR and non-CliDR groups (78.1% vs 78.8%). No significant differences were observed in the specific use of individual csDMARDs (eg, MTX: 59.4% vs 46.9%), biologic and targeted synthetic disease- modifying antirheumatic drugs (b/tsDMARDs) (9.4% vs 13.3%) or glucocorticoids (25.0% vs 25.7%). Detailed baseline characteristics are presented in table 1. During the 5-year follow-up after remission, 76/145 (52.4%) of patients underwent drug tapering, with 19/32 (59.4%) in the CliDR group and 57/113 (50.4%) in the non-CliDR group. A similar proportion of patients in the CliDR and non-CliDR groups maintained their original regimen (7/32 (21.9%) vs 17/113 (15.0%)). However, treatment intensification due to disease relapse—either by increasing dose/DMARDs (10/32 (31.3%) vs 62/113 (54.9%)) or switching agents (2/32 (6.3%) vs 8/113 (7.1%))—was notably more frequent in the non-CliDR group. DMARD switches due to adverse events (1/32 (3.1%) vs 8/113 (7.1%)) or other reasons (1/32 (3.1%) vs 2/113 (1.8%)) occurred at low frequencies. The distri- bution of tapered drug classes was well balanced between the CliDR and non-CliDR groups, with no significant differences (Glucocorticoids: 31.3% vs 16.8%, p=0.074; csDMARDs: 18.8% vs 23.9%, p=0.543; b/tsDMARDs: 9.4% vs 9.7%, p=0.952). CliDR associates with higher sustained remission rates and longer remission duration Despite a progressive decline in the sustained remission rate over the 5-year follow-up period, the rate at 5 years was significantly higher in the CliDR group (62.5%; 95% CI

Li H, et al . RMD Open 2026; 12 :e006387. doi:10.1136/rmdopen-2025-006387

Rheumatoid arthritis

Table 1 Baseline characteristics of patients with CliDR or non-CliDR CliDR (n=32)

non-CliDR (n=113)

P value

Female, n (%)

27 (84.4)

100 (88.5)

0.749 0.945 0.072 0.125 0.914

Age, years, mean±SD

56±13

54±14

Disease duration, years, mean±SD

10±8

10±6

Smoking, n (%)

3 (1.8) 2 (6.3)

2 (9.4)

RA family history, n (%)

10 (8.8) 0.5±0.9 0.5±1.2 2.1±0.3

TJC28, mean±SD SJC28, mean±SD

0±0 0±0

<0.001 <0.001 <0.001 <0.001 <0.001

DAS28-CRP, mean±SD ESR, mm/hour, mean±SD CRP, mg/L, mean±SD RF positivity, n (%) Anti-CCP positivity, n (%)

1.6±0.2 9.9±4.4 2.8±2.1 18 (56.3) 31 (96.9) 14 (43.8)

29.2±18.9 6.3±6.7 87 (77.0) 109 (96.5) 55 (48.7)

0.020 1.000 0.623 0.576 0.371 1.000 0.499 1.000 1.000 0.391 0.658 0.820 0.830 0.103 0.812 0.687 0.939 0.213 0.553 0.898 0.540 0.860

Extra articular manifestations, n (%)

Rheumatoid nodules, n (%)

1 (3.1) 2 (6.3)

9 (8.0)

Secondary Sjögren’s syndrome, n (%)

16 (14.2) 16 (14.2)

ILD, n (%)

5 (15.6)

Pleuritis, n (%) Vasculitis, n (%) Others, n (%)

1 (3.1)

0 (0)

2 (1.8) 2 (1.8)

1 (3.1)

Comorbidities, n (%)

9 (28.1) 4 (12.5)

41 (36.3)

Diabetes, n (%)

9 (8.0) 3 (2.7)

Hashimoto’s goitre, n (%)

0 (0)

Hypertension, n (%) Osteoporosis, n (%) Osteoarthritis, n (%)

9 (28.1) 5 (16.6) 7 (21.9) 9 (28.1) 8 (25.0) 19 (59.4) 20 (62.5) 14 (43.8) 6 (18.8)

34 (30.1) 34 (30.1) 27 (23.9) 36 (31.9) 29 (25.7) 53 (46.9) 64 (56.6) 48 (42.5) 27 (23.9) 15 (13.3) 89 (78.8)

Others, n (%)

Glucocorticoids, n (%)

csDMARDs

MTX, n (%) LEF, n (%) HCQ, n (%) SASP, n (%)

b/tsDMARDs, n (%)

3 (9.4)

DMARDs combination, n (%) 0.938 Anti-CCP, anti-cyclic citrullinated peptide antibodies; b/tsDMARDs, biologic and targeted synthetic disease-modifying antirheumatic drugs; CliDR, clinical deep remission; CRP, C reactive protein; csDMARDs, conventional synthetic disease-modifying antirheumatic drugs; DAS28, 28-joint Disease Activity Score; ESR, erythrocyte sedimentation rate; HCQ, hydroxychloroquine; ILD, interstitial lung disease; LEF, leflunomide; MTX, methotrexate; RA, rheumatoid arthritis; RF, rheumatoid factor; SASP, sulfasalazine; SJC, swollen joint count; TJC, tender joint count. 25 (78.1)

contrast, during the non-tapering period, the hazard for patients in the CliDR group did not differ signifi- cantly from that of the non-CliDR group (HR=0.57, 95% CI 0.20 to 1.62; p=0.292). The significant inter- action indicates that the effect of tapering is attenu- ated in the CliDR group compared with the non-CliDR group. The HR for tapering in the CliDR group is

the product of the HR for tapering in non-CliDR and the interaction HR (8.47×0.26 = 2.20). Although the 95% CI and p value for this product were not directly estimated due to software limitations, the significant interaction term indicates that the effect of tapering is significantly attenuated in the CliDR group compared with the non-CliDR group.

Li H, et al . RMD Open 2026; 12 :e006387. doi:10.1136/rmdopen-2025-006387

RMD Open

Figure 2 Comparison of long-term outcomes between clinical deep remission (CliDR) and non-CliDR groups over 5 years (60 months). (A) Proportion of patients in Disease Activity Score in 28 joints using C reactive protein remission during 5-year post- remission follow-up visits. (B) Kaplan-Meier analysis of survival probability.

Among the covariates included in the multivariable model, family history of rheumatic disease (HR=1.01, 95% CI 0.47 to 2.15; p=0.986) and RF titre (HR=1.00, 95% CI 1.00 to 1.001; p=0.447) were not significantly associated with the outcome. The presence of comorbid- ities showed a trend toward a protective effect, though it did not reach statistical significance (HR=0.61, 95% CI 0.37 to 1.02; p=0.057). DISCUSSION This study demonstrates the prognostic benefits of CliDR for maintaining long-term remission in RA in a real-world setting. We found that patients who achieved

CliDR—defined as the absence of swollen and tender joints combined with normal inflammatory markers— exhibited significantly higher rates of sustained remis- sion over 5 years. Notably, among those undergoing drug tapering, patients who had attained CliDR prior to tapering showed a superior ability to maintain remission compared with those in non-CliDR remission. The treat-to-target (T2T) strategy, supported by current EULAR, ACR and Asia Pacific League of Associations for Rheumatology (APLAR) recommendations, empha- sises sustained remission as a key therapeutic objective to prevent structural damage and optimise long-term outcomes. 1 Current recommendations by EULAR, ACR

Table 2 Univariable and multivariable cox regression analyses of predictors for the first investigator-reported relapse after remission

Univariate analysis

Multivariable analysis

Variable

HR (95%CI)

P value HR (95%CI)

P value

Group (CliDR vs non-CliDR) Tapering status (yes vs no) Age (per 1-year increase) Family history (yes vs no)

0.53 (0.29 to 0.98) 4.42 (2.78 to 7.02) 1.01 (1.00 to 1.03) 2.18 (1.09 to 4.37) 0.66 (0.35 to 1.22) 1.01 (0.97 to 1.04) 1.00 (1.00 to 1.003) 0.72 (0.47 to 1.12) 1.00 (1.00 to 1.001) 1.13 (0.69 to 1.92) 0.53 (0.33 to 0.87)

0.040*

0.57 (0.20 to 1.62) 8.47 (5.01 to 14.32)

0.292

<0.001*

<0.001

0.107 0.028* 0.185 0.663 0.820 0.145 0.075* 0.634 0.012*

1.01 (0.47 to 2.15)

0.986

Sex (female vs male)

Disease duration (per 1-year increase) Anti-CCP titre (per 1-unit increase)

Extra-articular manifestations (present vs absent)

RF titre (per 1-unit increase)

1.00 (1.00 to 1.001)

0.447

Smoking (yes vs no)

Comorbidities (yes vs no)

0.61 (0.37 to 1.02) 0.26 (0.07 to 0.98)

0.057 0.046

CliDR×tapering status (interaction)

Variable coding: For categorical variables, the reference category is the absence of the characteristic (eg, no, absent, male). For continuous variables, the HR corresponds to a one-unit increase. Time-dependent covariate: Tapering status was modelled as a time-dependent covariate (see Methods). The interaction term (CliDR×tapering status) tests whether the effect of tapering differs between groups. In the multivariable model, the HR for CliDR reflects its effect during the non-tapering period (ie, before tapering or among patients who never tapered). *Multivariable model inclusion: Variables with p<0.1 in the univariable analysis were entered into the multivariable model. Anti-CCP, anti-cyclic citrullinated peptide antibody; CliDR, clinical deep remission; RF, rheumatoid factor.

Li H, et al . RMD Open 2026; 12 :e006387. doi:10.1136/rmdopen-2025-006387

Rheumatoid arthritis

and APLAR emphasise sustained remission as a key therapeutic objective, requiring continuous control of inflammation to prevent structural damage and opti- mise long-term outcomes. 11–13 However, both in clinical studies and real-world practice, relapse of RA remains a common challenge. 14 15 The findings indicate that drug tapering is a risk factor for relapse in univariable analysis and is confirmed as an independent risk factor in multivariable anal- ysis. Further analysis of the interaction between CliDR status and tapering reveals that drug tapering is associ- ated with an increased risk of relapse in the non-CliDR group compared to the CliDR group. This suggests that tapering may be relatively safe in CliDR patients, whereas in non-CliDR patients it exposes an already unstable immunologic milieu, resulting in disproportionately higher relapse rates. In previous studies, sustained remission rates are not satisfactory, especially when tapering the DMARDs. 16–18 A systematic review reported that four studies on synthetic DMARD showed flare rates ranging from 8% at 24 weeks to 63% at 4 months after de-escalation, 15 studies on tumour necrosis factor blockers reported estimated flare rates of 0.26 (95% CI 0.17 to 0.39) and 0.49 (95% CI 0.27 to 0.73) for good-quality and moderate-quality studies respectively by meta-analysis, three studies on tocilizumab demonstrated flare rates of 41% after 6 months, 55% at 1 year and 87% at 1 year and three studies on abatacept de-escalation presented flare rates of 34% at 1 year, 41% at 1 year and 72% at 6 months. 19 Enhancing sustained remission in RA may be achiev- able through full suppression of residual inflamma- tion and individualised risk-stratified management for patients prone to disease flares. 20 Inflammatory markers, including CRP and ESR, are used to evaluate systemic inflammation, while joint tenderness and swelling assess local inflammation. CliDR, which requires normal systemic inflammatory markers and zero local inflamma- tion, shows that strict inflammation control is beneficial for achieving long-term clinical remission. Previous studies have also suggested that deep remis- sion contributes to the maintenance of remission in RA. In a randomised controlled trial (RCT), studies have suggested that patients achieving deep remission (DAS28 ≤ 1.98) have a higher probability of remaining in remission when tapering biologics. 21 22 In a different study, the ARCTIC study’s more rigorous treatment target (DAS44<1.6 plus 0 of 44 swollen joint count) resulted in more patients achieving ACR/EULAR Boolean remis- sion during follow-up than in the Norwegian Very Early Arthritis Clinic (NOR‑VEAC) study (DAS28<2.6). 22 This view is also supported by the PREDICTRA (ImPact of Residual Inflammation Detected via Imaging TEch- niques, Drug Levels and Patient Characteristics on the Outcome of Dose TaperIng of Adalimumab in Clinical Remission Rheumatoid ArThritis (RA) Patients) data, as 64% of patients with established RA (mean disease duration of 12.9 years) who were in deep, long remission

(mean DAS28(ESR) of 1.7) for a mean of 5.4 years did not experience a flare after bDMARD tapering. 23 The HONOR (Humira discontinuation without func- tional and radiographic damage progressioN follOwing sustained Remission) study identified DAS28(ESR) ≤ 2.16 as a critical cut-off point for predicting flare; 78% of patients with mean DAS28(ESR) ≤ 2.16 at the time of adali- mumab withdrawal maintained remission after 6 months (vs 2% for DAS28(ESR)>2.16, <2.6). 24 In comparison with these studies, aiming for a stricter remission defini- tion may further enhance the potential benefits of a T2T strategy. The concept of ‘imaging remission’—defined as the absence of power-Doppler signal or MRI osteitis—has been proposed as an ultimate treatment goal. However, recent randomised trials found that imaging-guided tapering did not significantly reduce relapse rates beyond what was achieved with stringent clinical remission criteria alone. 25 26 Given technical and resource constraints asso- ciated with routine imaging, CliDR represents a more accessible and clinically actionable target for widespread use. Although patients achieving CliDR experience lower relapse rates during dose tapering, determining ‘when to reduce’ and ‘whether to stop’ therapy remains a crit- ical unmet need for individualised care. Recent evidence indicates that deep-learning imaging combined with multi-omics integration can accurately forecast disease activity and drug response, enabling data-driven, patient- specific decisions on tapering or withdrawal and shifting RA management from a one-size-fits-all approach to precision-based stratification. 27 This study has several limitations, including: (1) poten- tial selection bias from single-centre enrolment, which may restrict generalisability to broader populations due to institutional-specific treatment protocols and patient demographics; (2) restricted sample size reducing power to detect inter-group differences, although the sample size (n=145) provided adequate power (>85%) to detect moderate effect sizes (HR ≥ 1.8), it was underpowered (62%) to identify small-to-moderate effects (HR=1.5), potentially missing clinically relevant but statistically marginal differences; (3) third, because fewer than 10% of participants received bDMARDs, we could not eval- uate whether CliDR also predicts successful biologic tapering; dedicated studies or larger registries enriched with bDMARD-treated patients are required to address this question; (4) finally, as 97% of our cohort were ACPA-positive, we were unable to assess the influence of serostatus on outcomes. Future multicentre studies with broader serological representation and randomised trials are needed to confirm the generalisability of our findings. Furthermore, integrating PROs into the defini- tion of CliDR constitutes an important avenue for future research, as it may capture a distinct dimension of disease burden. In conclusion, our study demonstrates that achieving CliDR is a strong predictor of sustained remission and

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RMD Open

a lower risk of flare in patients with RA. Importantly, our findings suggest that the achievement of CliDR may modify the risk associated with treatment tapering, iden- tifying a patient subgroup in which de-escalation could be safely considered. While these results require valida- tion in larger, multicentre RCTs to establish causality and address potential confounding, they underscore the prognostic value of a stringent remission criterion. Contributors HL and MZ performed data collection and analysis. HL drafted the manuscript. HZ and CL participated in data collection. JG revised the manuscript. YJ and RL conceived the study and revised the manuscript. All authors approved the submitted version. RL is the guarantor of this work. Funding This work was supported by The National Key R&D Program of China (2022YFC3602000) and The National Natural Science Foundation of China (92374202). Competing interests None declared. Patient consent for publication Not applicable. Ethics approval This study involves human participants. This study was approved by the institutional research ethics committee of the Peking University People’s Hospital (No. 2018PHB006-01). Participants gave informed consent to participate in the study before taking part. Provenance and peer review Not commissioned; externally peer reviewed. Data availability statement Data are available upon reasonable request. The data that support the findings of this study contain sensitive patient health information and are subject to privacy regulations under the ethical approval granted for this research. Therefore, they are not publicly available. Deidentified data can be made available to qualified researchers on reasonable request, subject to the approval of the institutional ethics committee and the execution of a data use agreement. Requests should be directed to the corresponding author at liru@pkuph.edu.cn. Open access This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: https://creativecommons.org/licenses/by-nc/4.0/.

Arthritis for their use as clinical trial end points. Arthritis Rheumatol 2017;69:518–28. 8 Liu J-J, Li R, Gan Y-Z, et al . Clinical deep remission and related factors in a large cohort of patients with rheumatoid arthritis. Chin Med J (Engl) 2019;132:1009–14. 9 Sun X, Li R, Cai Y, et al . Clinical remission of rheumatoid arthritis in a multicenter real-world study in Asia-Pacific region. Lancet Reg Health West Pac 2021;15:100240. 10 Wells G, Becker J-C, Teng J, et al . Validation of the 28-joint Disease Activity Score (DAS28) and European League Against Rheumatism response criteria based on C-reactive protein against disease progression in patients with rheumatoid arthritis, and comparison with the DAS28 based on erythrocyte sedimentation rate. Ann Rheum Dis 2009;68:954–60. 11 Smolen JS, Landewé RBM, Bergstra SA, et al . EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis 2023;82:3–18. 12 England BR, Smith BJ, Baker NA, et al . 2022 American College of Rheumatology guideline for exercise, rehabilitation, diet, and additional integrative interventions for rheumatoid arthritis. Arthritis Rheumatol 2023;75:1299–311. 13 Lau CS, Chia F, Dans L, et al . 2018 update of the APLAR recommendations for treatment of rheumatoid arthritis. Int J of Rheum Dis 2019;22:357–75. 14 Tageldin M, Wilson N, Yin Y, et al . A real-world 2-year prospective study of medication tapering in patients with well-controlled rheumatoid arthritis within the rheumatoid arthritis medication tapering (RHEUMTAP) cohort. Rheumatology (Oxford ) 2023;62:iv8–13. 15 Holten K, Paulshus Sundlisæter N, Sexton J, et al . Agreement between patient-reported flares and clinically significant flare status in patients with rheumatoid arthritis in sustained remission: data from the ARCTIC REWIND trials. RMD Open 2024;10:e004444. 16 Lillegraven S, Paulshus Sundlisæter N, Aga A-B, et al . Effect of tapered versus stable treatment with tumour necrosis factor inhibitors on disease flares in patients with rheumatoid arthritis in remission: a randomised, open label, non-inferiority trial. Ann Rheum Dis 2023;82:1394–403. 17 Lafita FR. In RA in remission for >1 y, tapering TNFi to discontinuation did not meet noninferiority criteria compared with stable TNFi for disease flare at 12 mo. Ann Intern Med 2023;176:JC139. 18 Tascilar K, Hagen M, Kleyer A, et al . Treatment tapering and stopping in patients with rheumatoid arthritis in stable remission (RETRO): a multicentre, randomised, controlled, open-label, phase 3 trial. Lancet Rheumatol 2021;3:e767–77. 19 Kuijper TM, Lamers-Karnebeek FBG, Jacobs JWG, et al . Flare rate in patients with rheumatoid arthritis in low disease activity or remission when tapering or stopping synthetic or biologic DMARD: a systematic review. J Rheumatol 2015;42:2012–22. 20 Schett G, Emery P, Tanaka Y, et al . Tapering biologic and conventional DMARD therapy in rheumatoid arthritis: current evidence and future directions. Ann Rheum Dis 2016;75:1428–37. 21 Tanaka Y, Smolen JS, Jones H, et al . The effect of deep or sustained remission on maintenance of remission after dose reduction or withdrawal of etanercept in patients with rheumatoid arthritis. Arthritis Res Ther 2019;21:164. 22 Norvang V, Brinkmann GH, Yoshida K, et al . Achievement of remission in two early rheumatoid arthritis cohorts implementing different treat-to-target strategies. Arthritis Rheumatol 2020. 23 Emery P, Burmester GR, Naredo E, et al . Adalimumab dose tapering in patients with rheumatoid arthritis who are in long-standing clinical remission: results of the phase IV PREDICTRA study. Ann Rheum Dis 2020;79:1023–30. 24 Hirata S, Saito K, Kubo S, et al . Discontinuation of adalimumab after attaining disease activity score 28-erythrocyte sedimentation rate remission in patients with rheumatoid arthritis (HONOR study): an observational study. Arthritis Res Ther 2013;15:R135. 25 Dale J, Stirling A, Zhang R, et al . Targeting ultrasound remission in early rheumatoid arthritis: the results of the TaSER study, a randomised clinical trial. Ann Rheum Dis 2016;75:1043–50. 26 Møller-Bisgaard S, Hørslev-Petersen K, Ejbjerg B, et al . Effect of Magnetic Resonance Imaging vs Conventional Treat-to-Target Strategies on Disease Activity Remission and Radiographic Progression in Rheumatoid Arthritis: The IMAGINE-RA Randomized Clinical Trial. JAMA 2019;321:461–72. 27 Sun Y, Lin J, Chen W. Artificial intelligence in rheumatoid arthritis. Rheumatol Autoimmun 2025;5:88–100.

ORCID iDs Haihui Li https://orcid.org/0009-0005-0274-3996 Huaqun Zhu https://orcid.org/0000-0001-9146-3753

REFERENCES 1 Smolen JS, Aletaha D, Bijlsma JWJ, et al . Treating rheumatoid arthritis to target: recommendations of an international task force. Ann Rheum Dis 2010;69:631–7. 2 Kjørholt KE, Sundlisæter NP, Aga A-B, et al . Three-year results of tapering tumor necrosis factor inhibitor to withdrawal compared to stable tumor necrosis factor inhibitor among patients with rheumatoid arthritis in sustained remission: a multicenter randomized trial. Arthritis Rheumatol 2025;77:1327–36. 3 Lillegraven S, Paulshus Sundlisæter N, Aga A-B, et al . Effect of Half- Dose vs Stable-Dose Conventional Synthetic Disease-Modifying Antirheumatic Drugs on Disease Flares in Patients With Rheumatoid Arthritis in Remission: The ARCTIC REWIND Randomized Clinical Trial. JAMA 2021;325:1755–64. 4 Einarsson JT, Willim M, Ernestam S, et al . Prevalence of sustained remission in rheumatoid arthritis: impact of criteria sets and disease duration, a nationwide study in Sweden. Rheumatology (Oxford) 2019;58:227–36. 5 Smolen JS, Breedveld FC, Schiff MH, et al . A simplified disease activity index for rheumatoid arthritis for use in clinical practice. Rheumatology (Oxford) 2003;42:244–57. 6 Aletaha D, Nell VPK, Stamm T, et al . Acute phase reactants add little to composite disease activity indices for rheumatoid arthritis: validation of a clinical activity score. Arthritis Res Ther 2005;7:R796–806. 7 Mack ME, Hsia E, Aletaha D. Comparative assessment of the different American College of Rheumatology/European League Against Rheumatism Remission Definitions for Rheumatoid

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Spondyloarthritis

ORIGINAL RESEARCH Development and validation of a new ultrasound score (SONAR-7) for synovitis in psoriatic arthritis and axial spondyloarthritis Gehad G Elsehrawy ‍ ‍, 1,2 Delphine S Courvoisier, 1 Erik Deman, 3 Diana Dan, 4 Raphael Micheroli ‍ ‍, 5 Hans Ziswiler, 6 Pascal Zufferey, 7 Laure Brulhart, 8 Michael J Nissen ‍ ‍ 1

To cite: Elsehrawy GG, Courvoisier DS, Deman E, et al . Development and validation of a new ultrasound score (SONAR-7) for synovitis in psoriatic arthritis and axial spondyloarthritis. RMD Open 2026; 12 :e006802. doi:10.1136/ rmdopen-2026-006802 ► Additional supplemental material is published online only. To view, please visit the journal online (https://doi.org/10.1136/ rmdopen-2026-006802).

ABSTRACT Objectives Development of a new ultrasound (US) synovitis score (SONography in Arthritis and Rheumatism (SONAR)-7) with evaluation of its diagnostic performance in a cohort of patients with psoriatic arthritis (PsA) and axial spondyloarthritis (axSpA), in comparison with healthy controls (HC). Methods We included 121 participants: 41 patients with PsA and 39 patients with axSpA, from six Swiss hospitals and 41 HC. All participants underwent a clinical examination of joints (68/66 tender joint count/swollen joint count (SJC)), followed by a detailed musculoskeletal US examination of 22 joints to assess for greyscale (GS) and power Doppler (PD) synovitis in adherence with the definitions established by the Outcome Measures in Rheumatology US working group.

is characterised by joint, tendon and enthe- seal lesions (mechanical and inflammatory) in both peripheral joints and the axial skel- eton. This manifests as synovitis, tenosyno- vitis and enthesitis, leading to progressive damage, functional impairment, disability and reduced quality of life over time. 1 Among the articular changes observed in PsA, synovitis stands out as a hallmark feature, with prevalence rates ranging from 10% to 100% in previous ultrasound (US) studies. 2 It has also been reported as an early finding in asymptomatic patients with psori- asis, suggesting a preclinical stage of PsA. 3 4 Even though spinal inflammation is the main feature of axSpA, many patients have concom- itant peripheral arthritis. Previous studies WHAT IS ALREADY KNOWN ON THIS TOPIC ⇒ Musculoskeletal joint ultrasound (US) is becoming increasingly used in patients with spondyloarthritis (SpA) for diagnostic, disease activity assessment and prognostic purposes; however, there is no con- sensus on the number and sites of the joints to be examined by US for the evaluation of both inflamma- tory and structural changes. WHAT THIS STUDY ADDS ⇒ Our study identified the key sonographic synovial lesions and the joint regions most specific for SpA (axial SpA and psoriatic arthritis) compared with healthy controls. HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY ⇒ This study is an important step towards identifying the simplest and least time-consuming set of le- sions and joints that should be examined by US in patients with SpA to determine the most useful and feasible synovitis score for routine clinical practice.

Received 31 January 2026 Accepted 27 March 2026

Results The ‘SONAR-7’ score incorporated GS and PD lesions across 14 joints, including four

metacarpophalangeal joints, four distal interphalangeal joints of the hands, two metatarsophalangeal joints, knees and wrists. It demonstrated an area under the receiver operating characteristic curve of 0.831 (95% CI 0.76 to 0.90), with an excellent specificity (95.1%) and moderate sensitivity (44%), comparable to existing US scores. The inflammatory components of the SONAR-7 correlated significantly with clinical measures of inflammation and disease activity (correlation: 0.37 for SJC-28, 0.33 for Disease Activity in Psoriatic Arthritis and 0.48 for US enthesitis). New bone formation in the same joints was associated with the Health Assessment Questionnaire (p=0.035) and Bath Ankylosing Spondylitis Metrology Index (p=0.016). Conclusion The SONAR-7 score represents a fast and effective US-based tool for the evaluation of inflammatory and structural joint involvement in patients with PsA and axSpA, with high specificity and meaningful associations with clinical and quality-of-life outcomes.

For numbered affiliations see end of article. permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ Group. Correspondence to Dr Gehad G Elsehrawy; gehadgamal@med.suez.edu.eg © Author(s) (or their employer(s)) 2026. Re-use

INTRODUCTION Psoriatic arthritis (PsA) and axial spondy- loarthritis (axSpA) are categorised under the umbrella of spondyloarthritis (SpA), which

Elsehrawy GG, et al . RMD Open 2026; 12 :e006802. doi:10.1136/rmdopen-2026-006802

RMD Open

Data collection For all participants, data were collected on age, sex, body mass index (BMI), comorbidities and current and past medications. Moreover, erythrocyte sedimentation rate, C reactive protein (CRP) and human leucocyte anti- gen-B27 were collected in patients with SpA. Clinical assessment Arthritis was evaluated using a 68-tender joint count (TJC-68) and a 66-swollen joint count (SJC-66). Enthesitis was assessed using the Spondyloarthritis Research Consortium of Canada (SPARCC) score 13 and the Maastricht Ankylosing Spondylitis Enthesitis Score (MASES). 14 For disease activity assessment, the following indices were recorded: the Disease Activity Score in 28 joints (DAS28-CRP) in all patients with SpA; the Ankylosing Spondylitis Disease Activity Score (ASDAS), the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), the Bath Ankylosing Spondylitis Functional Index and the Bath Ankylosing Spondylitis Metrology Index (BASMI) in patients with axSpA and the Disease Activity in Psori- atic Arthritis (DAPSA) score in patients with PsA. In addition, the Health Assessment Questionnaire (HAQ) 15 was completed by all patients with SpA. All participants completed the Global Physical Activity Questionnaire (GPAQ), 16 the short form-12 health survey (SF-12) 17 and the Fibromyalgia Rapid Screening Tool (FiRST). 18 US examination The US examination was performed by one of six board- certified rheumatologists, each with at least 10 years of experience in musculoskeletal US, and all are members of the Swiss SONAR group (https://www.irheuma.com/ de/rheumatology-a-z/s/sonar). Investigators performed the US evaluation on the same day as the clinical exam- ination. US assessment protocol This included a minimum of 22 joints (11 joints bilat- erally) in accordance with the ‘psoriatic arthritis sono- graphic 22-joint (PsA-Son22)’ score. 10 Moreover, any clinically tender or swollen joint was also examined by US. The standard 22 joints included: wrists, metacar- pophalangeal (MCP) joints 2, 3 and 5, proximal inter- phalangeal (PIP) joints 2–3, distal interphalangeal (DIP) joints 2–3, knees, metatarsophalangeal (MTP) joint 1 and foot PIP3 in a standardised manner according to European Alliance of Associations for Rheumatology (EULAR) and SONAR guidelines (for more details, see online supplemental file). 19 20 Ultrasonographic evaluation and grading were performed in adherence to the definitions established by the Outcome Measures in Rheumatology (OMERACT) US working group. 19 All joints were assessed by grey- scale ultrasound (GSUS) and power Doppler ultrasound (PDUS) for synovial hypertrophy (SH) and PD, respec- tively, and each lesion was scored individually according to the OMERACT semi-quantitative scale (range 0–3).

have reported a prevalence of arthritis ranging from 18% to 58% in axSpA. 5 Hence, accurate assessment of syno- vitis in both PsA and axSpA is crucial and standardisation is therefore essential. Power Doppler (PD) and B-mode (greyscale (GS)) US are more sensitive methods for detecting synovitis, tenosynovitis and enthesitis compared with clinical examination. 6 In addition, the US can evaluate disease activity and response to therapy more objectively, potentially allowing for more judicious adjustment of immunosuppressive medications. 7 However, there is no current consensus regarding the specific joints that should be examined by US for the evaluation of synovitis in SpA—both PsA and axSpA. 8 Since US examination can be time-consuming if applied to a large number of joints, identifying the minimal optimal combination of joints for US evaluation is crucial. 9 Several scores have been proposed for joint US assess- ment in patients with PsA, while no studies have evaluated the small peripheral joints in patients with axSpA. 10–12 Developing a fast and practical US scoring of synovitis for patients with PsA and axSpA that could be used in both interventional trials and clinical practice requires the evaluation of the lowest number of joints, while retaining high specificity for SpA. Moreover, the speci- ficity of a synovitis score in patients with axSpA compared with healthy individuals is unknown, particularly as mechanical stress and ageing might induce comparable changes in otherwise immunologically healthy persons. Given these unmet needs, the main aim of this research was to examine which combination of joints best discrim- inates between patients with SpA and healthy controls (HC). Consequently, we propose a concise and feasible joint US score (SONography in Arthritis and Rheuma- tism (SONAR)-7) for use by clinicians in daily practice. Thereafter, we aimed to assess the diagnostic perfor- mance of this US score, as well as its associations with disease activity measurements, in comparison with previ- ously published US scores.

PATIENTS AND METHODS Study population

This cross-sectional, multicentre study was conducted across Switzerland at six hospital rheumatology clinics. Patients with SpA registered within the Swiss Clinical Quality Management in Rheumatic Diseases (SCQM) registry were included in the study if they fulfilled either the Assessment of SpondyloArthritis International Society criteria or the Modified New York criteria for axSpA or the ClASsification criteria for Psoriatic ARthritis for PsA. Participants aged <18 years, HC with any inflammatory rheumatic disease, patients with SpA with another rheu- matic disease, patients with prior joint replacements or prosthetic implants and pregnant or breastfeeding women were excluded.

Elsehrawy GG, et al . RMD Open 2026; 12 :e006802. doi:10.1136/rmdopen-2026-006802

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