Rheumatoid arthritis

Severe? Refractory? Resistant? EULAR sets out its definition of difficult-to-treat RA


A definition of “difficult-to-treat” rheumatoid arthritis has been proposed by the European League Against Rheumatism (EULAR) to develop treatment guidelines.

The classification based on treatment failure history, the presence of active or symptomatic disease and clinical perception will help provide a “robust and consistent identification” of this subgroup of patients, a EULAR task force concluded.

Defining this group of patients using the three criteria is the first step in improving treatment for this “under-served patient group”, they added.

To meet the definition for difficult to treat RA, patients should have been treated as per EULAR recommendations but have failed two or more biological disease-modifying antirheumatic drugs (DMARDS) after first trying more conventional therapies.

They should also have at least one from a list that includes moderate disease activity; signs and/or symptoms suggestive of active disease; inability to taper glucocorticoid treatment; rapid radiographic progression; and RA symptoms that are causing a reduction in quality of life.

And the patient’s management should also be perceived as problematic by the rheumatologist and/or the patient, the task force said.

Speaking with the limbic, co-author Dr Elena Nikiphorou, consultant rheumatologist and an honorary senior lecturer at Kings College London, said it was useful to define these patients as they will probably require a different approach in their management.

“It’s particularly important to know the ‘true’ difficult to treat RA patients and those in particular who do not respond to medical treatment and where we need to identify reasons for this so that we can give more targeted treatment.”

She added that she hoped UK clinicians would recognise and agree with the criteria set out in the definition and that there would be a more harmonised use of the term across countries.

Guidelines for the management of difficult to treat RA patients covering inflammatory and non-inflammatory factors underlying the condition is in development and is expected soon Dr Nikiphorou confirmed.

It follows an international survey of rheumatologists which highlighted difficulties in managing these patients and “confirmed the unmet need of this subpopulation of RA patients”, the EULAR paper published in the Annals of Rheumatic Diseases said.

The survey indicated that in addition to new drugs, new management approaches are also needed for the optimal treatment of these patients.

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