A total of 164 individuals participated in the survey, with a median age of 42 (19–75) years. Out of the total participants, 85 (51.8%) were female, 75 (45.7%) were male, and 4 (2.5%) chose not to disclose their gender. The median duration following graduation was 17 (1–50) years. There were participants from 27 countries (Fig. 1). There were 129 consultant rheumatologists, 16 residents, 18 physiatrists, 2 general practitioners, and 9 individuals from allied professions. A total of 115 individuals were employed at the university teaching hospital, while 26 were employed at the outpatient center, 23 at the tertiary referral center, 7 were at the rehabilitation center, and 12 at other facilities. Additionally, 27 participants were employed at private practice.

Country-wise distribution of respondents

The National Library of Medicine’s Medical Subject Headings (MeSH) introduced the definition of axSpA in 2022, and 151(92.1%) respondents were familiar with it. When assessing the patients in view of the Assessment in SpondyloArthritis International Society (ASAS) classification criteria for axSpA, 150 (91.5%) respondents used axSpA, nr-axSpA, or r-axSpA diagnostic terms. One hundred and forty-nine (90.9%) respondents were familiar with 2016 and 2022 updates of the ASAS-EULAR management recommendations for axSpA, with 8 (4.9%) responding ‘not sure’ and 7 (4.2%) responding ‘no’. A total of 97 (59.1%) respondents reported a special interest in axSpA, and 58 (35.4%) reported being a member of a dedicated axSpA clinic.

Ninety-nine (60.4%) participants reported assessing axSpA patients at 3-month follow-up visits, 54 (32.9%) at 6-month, 3 (1.8%) at 9-month, and 8 (4.9%) at 12-month follow-ups. A total of 128 (78.1%) participants stated that individuals with axSpA typically seek care from either the general rheumatology department or the axSpA outpatient clinic when they experience flares. Meanwhile, 14 (8.5%) participants were unsure, and 22 (13.4%) responded no. When a patient with suspected axSpA is first examined, the preferences for imaging tests for the sacroiliac joints to confirm the diagnosis and/or fulfill the ASAS classification criteria were as follows: 92 (56.8%) responders employed both magnetic resonance imaging (MRI) and X-ray, 20 (13.5%) MRI only, and 50 (30.5%) X-ray only. When X-ray examination of the sacroiliac joints in patients with suspected axSpA was normal/uninformative, the choices of testing were as follows: 39 (23.8%) respondents used both sacroiliac joint and spinal MRI and 123 (75%) sacroiliac joint MRI only. Seventy-two (43.9%) participants had a multidisciplinary team/clinic managing axSpA patients at their centers. Of the participants working with a multidisciplinary team, 60 reported that rheumatologists, 31 rheumatology specialist nurses, 51 physiotherapists, 12 occupational therapists, 23 cardiologists, 14 clinical psychologists, and 47 musculoskeletal radiologists were members of the team.

Out of the all participants, 73 (44.5%) were engaged in online/telephone follow-up consultations to monitor the health and treatment compliance of axSpA patients. The three countries with the highest number of respondents were compared in terms of using online/telephone follow-up consultations. Although Polish responders frequently relied on such consultations, there were no statistically significant differences among the three countries (22.2% for Türkiye, 42.9% for Poland, and 21.7% for the Czech Republic; p = 0.134). The axSpA activity and quality of life measures used in the assessment process were reported as follows: 142 (86.6%) participants used Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), 107 (65.2%) Ankylosing Spondylitis Disease Activity Score (ASDAS), 78 (47.6%) Bath Ankylosing Spondylitis Functional Index (BASFI), 42 (25.6%) Bath Ankylosing Spondylitis Metrology Index (BASMI), 18 (10.9%) Ankylosing Spondylitis Quality of Life Questionnaire (ASQOL), and 8 (4.9%) Work Productivity and Activity Impairment Questionnaire (WPAI). In addition, 16 (9.8%) participants reported using all scales. Six (3.7%) participants reported measuring the physical activity of axSpA patients using accelerometers. Four of these six participants were consultant rheumatologists, one was a physiatrist, and one was a resident. The factors seen as barriers to maintaining the recommended physical activity for patients with axSpA were as follows: high level of symptoms (pain, fatigue, stiffness) reported by 125 (76.2%) participants, depression or mood disorders by 88 (53.7%), absence of support from family, friends, and social workers by 63 (38.4%), and absence of advice from healthcare workers by 60 (36.6%) (Fig. 2). In axSpA, cardiovascular risk assessment priorities were the following: antihypertensive strategy was highlighted by 36, body weight control strategy by 40, lipid-lowering strategy by 34, smoking cessation strategy by 44, and all the mentioned by 147 participants. The number of participants who used the ASAS Health Index (ASAS HI) in their daily examination practice was 36 (21.9%); 99 (60.4%) did not use it; and 29 (17.7%) had no knowledge of this index.

The main barriers to maintaining physical activity in patients with axSpA

The axSpA patients who should be treated by nonsteroidal anti-inflammatory drugs (NSAIDs) were reported as follows: 133 (81.1%) respondents mentioned about patients with pain and stiffness, 60 (36.6%) -  patients tolerating low-medium doses of NSAIDs, 119 (72.6%) -  symptomatic patients with active inflammation who tolerate maximal doses, and 101 (61.6%) -  patients without NSAIDs side effects.

The glucocorticoid treatment strategies acceptable for the participants were as follows: glucocorticoid injections at the sites of articular and periarticular/enthesial inflammation (136 [82.9%] participants), short-term high-dose oral therapy (e.g., 50 mg/day) (22 [13.4%]), long-term low-dose oral therapy (9 [5.5%]), local and/or oral therapy for uveitis (110 [67.1%]), all approaches (7 [4.3%]), and none (5 [3.1%]) (Fig. 3). The top three countries were selected based on the number of participants (Türkiye, Poland, and Czech Republic); steroid use strategies among these three countries were compared with the Chi-square test. There was no statistically significant difference in the use of glucocorticoid injections at the sites of articular and periarticular/enthesial inflammation, short-term high-dose oral glucocorticoid therapy, and long-term anti-inflammatory glucocorticoid oral therapy at low doses (p > 0.05). There was only a significant difference between countries in steroid use for the management of uveitis (p = 0.02) (92.8% for Poland, 69.6% for the Czech Republic, and 50% for Türkiye). The prominent countries in terms of the use of short-term high-dose oral glucocorticoid therapy were Türkiye (n = 6), Poland (n = 4), Ukraine (n = 3), and the Czech Republic (n = 3). The prominent countries in terms of the use of long-term anti-inflammatory glucocorticoid oral therapy at low doses were Türkiye (n = 2), Poland (n = 2), and Croatia (n = 2).

AxSpA glucocorticoid treatment strategies acceptable for the survey participants

The conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) of choice for peripheral manifestations/arthritis of axSpA were methotrexate (103 [62.8%] participants), sulfasalazine (143 [87.2%]), and leflunomide (29 [17.7%]).

The scenarios where biologics such as tumor necrosis factor (TNF)-alpha inhibitors were preferred were as follows: 148 (90.2%) participants pointed to cases when different NSAIDs and non-pharmacological treatment modalities were ineffective, 135 (82.3%)  - when axSpA activity measured by composite measures (e.g. BASDAI, ASDAS) was persistently high, 26 (15.9%) -  when above low disease activity, and 100 (60.9%) -  when fast progression of structural damage on X-ray. (Fig. 4).

The main scenarios when biological drugs for axSpA are preferred the survey respondents

When TNF-alpha inhibitor therapy failed to suppress inflammation (secondary ineffectiveness, not side effects), the preferred treatment strategies were as follows: 44 (26.8%) participants reported administering another TNF-alpha inhibitor, 64 (39%) -  administering anti-IL-17 therapy, 32 (19.5%) -  administering a JAK inhibitor, and 91 (55.5%) reported that all three options were applicable. The number of participants who routinely applied non-pharmacological treatment modalities was 143 (87.2%). The number of participants who discussed the most preferred treatment modalities and best possible management plans with their patients with axSpA and/or their caregivers as part of a shared decision-making process was 146 (89%). The number of participants who considered costs incurred when evaluating the cost-effectiveness of imaging/treatment modalities, particularly biologic/targeted synthetic drugs, was 126 (76.8%).

The number of participants who encountered patients who developed axSpA after recovering from COVID-19 was 57 (34.8%).

An open-ended question was used to identify priorities in specialty training for diagnosis and management of patients with axSpA. The following three main themes were mentioned by the participants: assessment of inflammatory back pain (n = 40), radiologic examination (n = 37), and early diagnosis (n = 28).