EULAR definition of difficult-to-treat rheumatoid arthritis

Abstract

BackgroundDespite treatment according to the current management recommendations, a significant proportion of patients with rheumatoid arthritis (RA) remain symptomatic. These patients can be considered to have ‘difficult-to-treat RA’. However, uniform terminology and an appropriate definition are lacking.ObjectiveThe Task Force in charge of the “Development of EULAR recommendations for the comprehensive management of difficult-to-treat rheumatoid arthritis” aims to create recommendations for this underserved patient group. Herein, we present the definition of difficult-to-treat RA, as the first step.MethodsThe Steering Committee drafted a definition with suggested terminology based on an international survey among rheumatologists. This was discussed and amended by the Task Force, including rheumatologists, nurses, health professionals and patients, at a face-to-face meeting until sufficient agreement was reached (assessed through voting).ResultsThe following three criteria were agreed by all Task Force members as mandatory elements of the definition of difficult-to-treat RA: (1) Treatment according to European League Against Rheumatism (EULAR) recommendation and failure of ≥2 biological disease-modifying antirheumatic drugs (DMARDs)/targeted synthetic DMARDs (with different mechanisms of action) after failing conventional synthetic DMARD therapy (unless contraindicated); (2) presence of at least one of the following: at least moderate disease activity; signs and/or symptoms suggestive of active disease; inability to taper glucocorticoid treatment; rapid radiographic progression; RA symptoms that are causing a reduction in quality of life; and (3) the management of signs and/or symptoms is perceived as problematic by the rheumatologist and/or the patient.ConclusionsThe proposed EULAR definition for difficult-to-treat RA can be used in clinical practice, clinical trials and can form a basis for future research.

Correspondence on: ‘EULAR definition of difficult-to-treat rheumatoid arthritis’

“…We read with great interest the publication entitled 'EULAR definition of difficult-to-treat rheumatoid arthritis', which sought not only to provide a uniform terminology, but also to formulate an adequate definition to classify those patients with difficult-totreat rheumatoid arthritis (RA). 1 Resolution of this issue promises to be very useful in clinical practice and in the design of studies for future research.…”

Response to: ‘Correspondence on ‘EULAR definition of difficult-to-treat rheumatoid arthritis’’ by Novella-Navarroet al

“…Noteworthy, 96% of their multirefractory patients met the EULAR definition of D2T RA (box 1), 2 which supports the clinical usefulness of our definition. 1 As some members of our Task Force also conducted a study in D2T RA patients, 11 we feel it would be interesting to compare our results with those of Novella-Navarro et al, applying their slightly different criteria. 10 In our cross-sectional study, consecutive patients with RA, treated for at least 1 year, were prospectively enrolled and classified as having D2T RA if they fulfilled the EULAR definition (box 1).…”

“…10 In our cross-sectional study, consecutive patients with RA, treated for at least 1 year, were prospectively enrolled and classified as having D2T RA if they fulfilled the EULAR definition (box 1). 1 Patients with RA who did not fulfil all three criteria served as a control group.…”

“…10 In our study, 89% of the D2T RA patients (46 of 52) failed ≥2 csDMARDs. 11 As csDMARDs may be contraindicated and socioeconomic factors-including differences in the availability of (b/ts)DMARDs-may result in different treatment schedules between countries, the Task Force added two exceptions to the first criterion (box 1), 1 enabling that the patients who it would concern could still fulfil the D2T RA definition.…”

“…As second criterion of the EULAR definition, patients should have 'signs suggestive of active/progressive disease (defined as ≥1 of 5 prespecified items, box 1)'. 1 One of the prespecified items is having 'at least moderate disease activity'. This was reflected in our study with D2T RA patients having a significantly higher DAS28-ESR (Disease Activity Score assessing 28 joints using erythrocyte sedimentation rate) compared with non-D2T RA patients (median (IQR) 4.1 (3.5-6.1) vs 2.5 (1.8-3.3), p<0.001).…”