Difficult-to-Treat Rheumatoid Arthritis: What Does It Mean?

Written on 06 November 2020. Posted in Rheumatology News & Perspectives

Despite the frequently updated EULAR recommendations for the management of rheumatoid arthritis (RA), many patients remain symptomatic even after following the protocol. Those patients are referred to as difficult-to-treat and require peculiar disease management. The first step before making specific recommendations for the management of patients with difficult-to-treat RA is to clearly define the clinical condition.

After exploring the literature and interviewing rheumatologists at the international level, the EULAR Task Force in charge of this subject established a definition based on three types of criteria: a history of treatment failure, characterization of disease activity, and clinical perception of the practitioner and/or the patient.

History of treatment

Patients who fail after having been treated according to the recommendations of the EULAR and who have already received treatment with conventional synthetic DMARDs (unless contraindicated) and ≥2 biological DMARDs or targeted therapies with different mechanisms of action. Although it was proposed to add a notion of time to these criteria, this point was not taken up by the Task Force. It should also be noted that while treatments with conventional synthetic DMARDs are contraindicated, failure after ≥2 biological DMARDs or targeted therapy is sufficient to define RA that is difficult to treat. The Task Force also added the statement "Unless access to treatment is restricted due to economic factors" in order to incorporate the challenges that low-income countries may face.

Disease activity

The characterization of the activity of difficult-to-treat RA is defined by the presence of at least one of the following:

• a disease which activity is at least moderate (measured by validated composite criteria, such as the DAS28-ESR> 3.2 [disease activity score on 28 joints and including the measurement of erythrocyte sedimentation rate] or the CDAI> 10,
• the presence of signs and/or symptoms suggesting an active disease,
• the inability to gradually reduce corticosteroid therapy below 7.5 mg per day of prednisone or equivalent,
• an x-ray showing rapid progression (with or without clinical signs of disease activity),
• symptoms of polyarthritis indicating an altered quality of life.

Disease perception

Finally, the rheumatologist and/or the patient should perceive the disease as really problematic. Although subjective, this criterion was maintained by the Task Force.

EULAR calls for this definition to be used not only in studies but also in clinical practice.

Tags: rheumatoid arthritis, biologics

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