Unifying terminology for difficult-to-treat rheumatoid arthritis


Rheumatoid arthritis (RA) is an inflammatory autoimmune disease that causes pain, swelling and stiffness in the joints. It can also cause fatigue, and the underlying inflammation may affect other body systems. A significant proportion of people with rheumatoid arthritis (RA) still have symptoms despite receiving treatment according to the current management recommendations. These people can be considered to have ‘difficult-to-treat RA.” However, there is no uniform terminology or definitions to decide when this applies. The concept is referred to by many different terms, including severe, refractory, drug-resistant, or established RA. EULAR prefer the term ‘difficult-to-treat’ because it best capture the possible clinical scenarios. Being clear on terminology is important because people with difficult-to-treat RA may require a different approach.

EULAR intends to create recommendations for this neglected patient group. Agreeing on a clear definition of who has difficult-to-treat RA is an important first step. A task force was set up to draft a definition based on the results of an online survey conducted in rheumatologists to identify the key features of people with difficult-to-treat disease. The taskforce included rheumatologists, nurses, other health professionals, and patients.

Three criteria were agreed as mandatory elements of the definition of difficult-to-treat RA. The first is that before being classed as difficult-to-treat, people should have received treatment according to the EULAR recommendation, and failed to get a response from two or more biological or targeted synthetic disease-modifying antirheumatic drugs (b/tsDMARDs). They must also have at least one of the following: at least moderate disease activity; signs or symptoms of active disease; inability to taper glucocorticoid treatment; rapid radiographic progression; or symptoms causing a reduction in quality of life. The third criteria is that management of signs or symptoms should be perceived as problematic by either the rheumatologist or the patient.

EULAR hopes the proposed definition will enable robust and consistent identification of patients with difficult-to-treat RA. In addition, it can provide a platform to define a group of similar patients for research into difficult-to-treat RA. Further work is underway to provide detailed recommendations for management.