Rheumatoid arthritis

EULAR delivers a roadmap for difficult to treat RA


A EULAR Task Force has developed a “clinical roadmap” for the management of difficult-to-treat rheumatoid arthritis (D2T RA).

The Task Force found high-quality evidence was scarce but delivered two overarching principles and 11 points to consider concerning diagnostic confirmation of RA, evaluation of inflammatory disease activity, pharmacological and non-pharmacological interventions, treatment adherence, functional disability, pain, fatigue, goal setting and self-efficacy and the impact of comorbidities.

The three criteria for a definition of D2T RA were:

  • Treatment according to EULAR recommendations and failure of ≥two b/tsDMARDs (with different mechanisms of action) after failing csDMARD therapy (unless contraindicated)
  • Signs suggestive of active/progressive disease
  • The management of signs and/or symptoms is perceived as problematic by the rheumatologist and/or the patient.

It noted that all overarching principles and EULAR recommendations for the management of RA also apply to D2T RA.

Specific points to consider were:

  • If a patient has a presumed D2T RA, the possibility of misdiagnosis and/or the presence of a coexistent mimicking disease should be considered as a first step
  • Where there is doubt on the presence of inflammatory activity based on clinical assessment and composite indices, ultrasonography may be considered for this evaluation
  • Composite indices and clinical evaluation should be interpreted with caution in the presence of comorbidities, in particular obesity and fibromyalgia, as these may directly heighten inflammatory activity and/or overestimate disease activity
  • Treatment adherence should be discussed and optimised within the process of shared decision-making
  • After failure of a second or subsequent b/tsDMARD, and particularly after two tumour necrosis factor inhibitor (TNFi) failures, treatment with a b/tsDMARD with a different target should be considered
  • If a third or subsequent b/tsDMARD is being considered, the maximum dose, as found effective and safe in appropriate testing, should be used
  • Comorbidities that impact quality of life either independently or by limiting RA treatment options, should be carefully considered and managed
  • In patients with concomitant HBV/HCV infection, b/tsDMARDs can be used and concomitant antiviral prophylaxis or treatment should be considered in close collaboration with the hepatologist
  • In addition to pharmacological treatment, non-pharmacological interventions (ie, exercise, psychological, educational and self-management interventions) should be considered to optimise management of functional disability, pain and fatigue
  • Appropriate education and support should be offered to patients to directly inform their choices of treatment goals and management
  • Consider offering self-management programmes, relevant education and psychological interventions to optimise patient’s ability to manage their disease confidently

Read more in Annals of Rheumatic Diseases

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