OBJECTIVES: Patients with difficult-to-treat rheumatoid arthritis (RA) remain symptomatic despite treatment according to current European League Against Rheumatism (EULAR) management recommendations. These focus on early phases of the disease and pharmacological management. We aimed to identify characteristics of difficult-to-treat RA and issues to be addressed in its workup and management that are not covered by current management recommendations. METHODS: An international survey was conducted among rheumatologists with multiple-choice questions on disease characteristics of difficult-to-treat RA. Using open questions, additional items to be addressed and items missing in current management recommendations were identified. RESULTS: 410 respondents completed the survey: 50% selected disease activity score assessing 28 joints >3.2 OR presence of signs suggestive of active disease as characteristics of difficult-to-treat RA; 42% selected fatigue; 48% selected failure to ≥2 conventional synthetic disease-modifying antirheumatic drugs (DMARDs) AND ≥2 biological/targeted synthetic DMARDs; 89% selected inability to taper glucocorticoids below 5 mg or 10 mg prednisone equivalent daily. Interfering comorbidities, extra-articular manifestations and polypharmacy were identified as important issues missing in current management recommendations. CONCLUSIONS: There is wide variation in concepts of difficult-to-treat RA. Several important issues regarding these patients are not addressed by current EULAR recommendations.

Department of Genetics Cell and Immunobiology Semmelweis University Budapest Hungary

Department of Internal Medicine 3 Division of Rheumatology Medical University of Vienna Vienna Austria

Department of Rheumatology 1st Faculty of Medicine Charles University and Rheumatology Institute Prague Czech Republic

Department of Rheumatology 3rd Department of Internal Medicine Semmelweis University Budapest Hungary

Department of Rheumatology and Clinical Immunology Justus Liebig University Giessen Kerckhoff Clinic Bad Nauheim Bad Nauheim Germany

Department of Rheumatology and Clinical Immunology University Medical Center Utrecht Utrecht University Utrecht The Netherlands

Department of Rheumatology Cochin Hospital Assistance Publique Hôpitaux de Paris INSERM Clinical Epidemiology and Biostatistics PRES Sorbonne Paris Cité Paris Descartes University Paris France

Department of Rheumatology Faculty of Medicine University of Debrecen Debrecen Hungary

Department of Rheumatology Leiden University Medical Center Leiden The Netherlands

Institute of Infection Immunity and Inflammation University of Glasgow Glasgow UK

NIHR Manchester Musculoskeletal Biomedical Research Unit Central Manchester NHS Foundation Trust Manchester Academic Health Science Centre Manchester UK

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

EULAR definition of difficult-to-treat rheumatoid arthritis