OBJECTIVE: To 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). METHODS: An 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. RESULTS: Two 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). CONCLUSIONS: These 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.

• Keywords
• arthritis, fibromyalgia, inflammation, rheumatoid, ultrasonography,
• MeSH
• Medication Adherence MeSH
• Antirheumatic Agents administration & dosage   therapeutic use   MeSH
• Exercise MeSH
• Hepatitis B complications   drug therapy   MeSH
• Hepatitis C complications   drug therapy   MeSH
• Cognitive Behavioral Therapy MeSH
• Comorbidity MeSH
• Humans MeSH
• Arthritis, Rheumatoid complications   diagnosis   drug therapy   therapy   MeSH
• Symptom Assessment MeSH
• Patient Education as Topic MeSH
• Check Tag
• Humans MeSH
• Publication type
• Journal Article MeSH
• Research Support, Non-U.S. Gov't MeSH
• Practice Guideline MeSH
• Names of Substances
• Antirheumatic Agents MeSH