Batna Journal of Medical Sciences
Volume 9, Numéro 1, Pages 74-82
2026-01-02

Triple-negative Axial Spondyloarthritis: Navigating Diagnostic Uncertainty And Justifying Biologic Therapy Treatment



Authors : Remita Kamel . Slimani Samy . Boukredera Mohamed .

Abstract

Axial spondyloarthritis (axSpA) represents a spectrum of chronic inflammatory diseases with heterogeneous clinical presentations, ranging from radiographic ankylosing spondylitis (AS) to non-radiographic forms. The introduction of MRI and the ASAS classification criteria enabled earlier recognition, but significant diagnostic gaps persist,particularly in “triple-negative” patients who lack radiographic sacroiliitis, MRI-confirmed inflammation, and HLA-B27 positivity. These patients often display characteristic clinical features such as inflammatory back pain, enthesitis, and extra-articular manifestations, yet remain excluded from classification criteria and, consequently, from timely biologic access. Elevated inflammatory markers (CRP, ESR) are useful prognostic tools but lack sensitivity, leaving clinical pattern recognition central in many cases. Therapeutic dilemmas arise where international guidelines require objective inflammatory markers for biologic initiation, despite evidence that some patients without such markers may benefit from early intervention. The decision to initiate biologic DMARDs in triple-negative axSpA raises complex clinical, ethical, economic, and medico-legal challenges. Physicians must balance the risks of overtreatment with immunosuppressive therapy against the harms of undertreatment and disease progression. Shared decision-making, rigorous documentation, and consideration of pragmatic diagnostic labels such as “probable axSpA” may help bridge the gap. A structured clinical algorithm integrating clinical features, inflammatory markers, re-imaging, and therapeutic trial approaches is proposed to guide management in the absence of definitive biomarkers.

Keywords

Axial spondyloarthritis; diagnostic delay; triple-negative; classification criteria; biologic DMARDs.

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