Frailty in rheumatoid arthritis, psoriatic arthritis, and axial spondyloarthritis: Current evidence and knowledge gaps.

Frailty has recently emerged as a significant concern in the field of rheumatology due to the increasing representation of older adults with inflammatory arthritis (IA) and their heightened susceptibility to developing this condition. The impact of frailty on patient functioning, quality of life (QoL), and disability is substantial, and its relatively early onset in this population also places a burden on healthcare systems. This narrative review examines the prevalence, risk factors, management, and impact of frailty in rheumatoid arthritis (RA), axial spondyloarthritis (axSpA), and psoriatic arthritis (PsA). A comprehensive search of the MEDLINE/PubMed, SCOPUS, and DOAJ databases was conducted to identify relevant articles. Several factors contribute to the development of frailty, with the strongest evidence linking the condition to advanced age, disease activity and duration, pain intensity, and nutritional status. The absence of standardised assessment tools, combined with substantial heterogeneity in frailty definitions across both the general and rheumatological populations, creates difficulties when comparing findings across studies. Treatment of the underlying disease also affects frailty. While methotrexate has been shown to offer protection, and NSAIDs/glucocorticoids have been demonstrated to be detrimental, biologic DMARDs appear to have a neutral effect on frailty. However, their capacity to reduce long-term disease activity may offer indirect benefits that have not yet been reflected in direct data. Furthermore, the treatment of frail patients is challenging due to their increased susceptibility to adverse events and reduced treatment response. Non-pharmacological interventions, particularly those that incorporate individualised physical activity and a balanced diet rich in omega-3 fatty acids, have been identified as playing a critical role in the management of frailty. Frailty is a significant challenge in inflammatory rheumatic diseases, though studies in rheumatoid arthritis currently dominate the evidence base. While this review synthesises the available, disease-specific data for PsA and axSpA, many clinical insights for these populations still rely on extrapolation. Consequently, these findings are framed as hypothesis-generating, highlighting a critical need for further targeted research to bridge these evidence gaps.