EULAR points to consider for the management of difficult-to-treat rheumatoid arthritis

Abstract

ObjectiveTo develop evidence-based European Alliance of Associations for Rheumatology (EULAR) points to consider (PtCs) for the management of difficult-to-treat rheumatoid arthritis (D2T RA).MethodsAn EULAR Task Force was established comprising 34 individuals: 26 rheumatologists, patient partners and rheumatology experienced health professionals. Two systematic literature reviews addressed clinical questions around diagnostic challenges, and pharmacological and non-pharmacological therapeutic strategies in D2T RA. PtCs were formulated based on the identified evidence and expert opinion. Strength of recommendations (SoR, scale A–D: A typically consistent level 1 studies and D level 5 evidence or inconsistent studies) and level of agreement (LoA, scale 0–10: 0 completely disagree and 10 completely agree) of the PtCs were determined by the Task Force members.ResultsTwo overarching principles and 11 PtCs were defined 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 SoR varied from level C to level D. The mean LoA with the overarching principles and PtCs was generally high (8.4–9.6).ConclusionsThese PtCs for D2T RA can serve as a clinical roadmap to support healthcare professionals and patients to deliver holistic management and more personalised pharmacological and non-pharmacological therapeutic strategies. High-quality evidence was scarce. A research agenda was created to guide future research.

Preferable outcome of Janus kinase inhibitors for a group of difficult-to-treat rheumatoid arthritis patients: from the FIRST Registry

“…Therefore, although this study included factors related to some comorbidities, namely, the coexistence of chronic lung diseases and serum titres of creatinine, there may be other comorbidities confounding the outcomes such as hepatic disorders and neurological disorders. In addition, our data does not include non-inflammatory symptoms such as fibromyalgia, which are included as a major criterion of the EULAR definition [ 3 ] as well as a point to consider in the management of D2T RA [ 4 ]. The number of past fractures was also small, suggesting our data about comorbidities was insufficient.…”

“…The European Alliance of Associations for Rheumatology (EULAR) launched a new definition of D2T RA in 2020 [ 3 ] and points to consider for its management in 2022 [ 4 ]. The definition comprises 3 criteria: treatment failure history, characterisation of active/symptomatic disease, and clinical perception.…”

Correspondence on “Re‐examining remission definitions in rheumatoid arthritis: considering the 28‐Joint Disease Activity Score, C‐reactive protein level and patient global assessment” by Felson et al

“…These patients, in so-called PGA near-remission, are exposed to the risk of overtreatment because their disease cannot be improved by additional immunosuppression or immunomodulation. However, they still endure significant impact of non-diseaseactivity manifestations and outcomes of the disease (8), which were recently touched on in the EULAR points to consider for the management of difficult-to-treat RA (9). The use of the ACR/EULAR remission definitions in clinical practice was explicitly predicted in the original 2011 report (10) and has been extensively adopted as part of the treat-to-target strategy.…”

Correspondence on ‘Re-examining remission definitions in rheumatoid arthritis: considering the 28-joint Disease Activity Score, C reactive protein level and patient global assessment’

“…However, they still endure significant impact of non-disease activity manifestations and outcomes of the disease, 8 which were recently touched on in the EULAR points to consider for the management of difficultto-treat RA. 9 The use of the ACR/EULAR remission definitions in clinical practice was explicitly predicted in the original 2011 report 10 and has been extensively adopted as part of the Treatto-Target strategy. Thus, the implications of these definitions are more extensive than those for clinical trials only.…”

“…These patients, in so-called ‘PGA-near-remission’, are exposed to the risk of overtreatment, because their disease cannot be improved by additional immunosuppression/immunomodulation. However, they still endure significant impact of non-disease activity manifestations and outcomes of the disease,8 which were recently touched on in the EULAR points to consider for the management of difficult-to-treat RA 9. The use of the ACR/EULAR remission definitions in clinical practice was explicitly predicted in the original 2011 report10 and has been extensively adopted as part of the Treat-to-Target strategy.…”