Abstract
BACKGROUND: Axial spondyloarthritis (axSpA) exhibits notable sex-related differences, particularly in Asian populations, influenced by genetic, cultural, and healthcare factors. This systematic review and meta-analysis assess sex-specific disparities in axSpA among Asian patients. METHODS: A systematic search in PubMed, Embase, and Google Scholar (up to January 30, 2025) included studies reporting sex-specific differences in clinical presentation, diagnostic delay, treatment response, and quality of life. The study included 31,523 males and 10,815 females. Risk of bias was assessed using the ROBINS-I tool. Meta-analysis was performed using R and Jamovi, with heterogeneity assessed via I(2) statistics. RESULTS: Thirty studies comprising 31,523 male and 10,815 female axSpA patients were included. Males had an younger age of onset and diagnosis (MD: -3.48 years; 95% CI: -4.78 to -2.17; -3.57 years; 95% CI: -5.25 to -1.89). No significant differences in diagnostic delay were observed. (MD: -0.62 years; 95% CI: -1.55 to 0.32; p = 0.0551). Females exhibited higher disease activity scores (BASDAI MD: -0.57; 95% CI: -0.86 to -0.27; p = 0.00211) and inflammatory markers (ESR MD: -3.99 mm/h; p = 0.0476), whereas males showed greater radiographic progression (BASRI MD: 2.60; 95% CI: 1.86-3.34; p < 0.001). HLA-B27 positivity was higher in males (79.5% vs. 69.2%). Treatment adherence was lower in females. DISCUSSION: This study highlights critical sex-based disparities in axSpA among Asian populations, particularly regarding disease onset, progression, and treatment response. The findings emphasize the need for sex-specific diagnostic and therapeutic strategies to improve patient outcomes. REGISTRATION: The review protocol was registered on PROSPERO (CRD42025637163).