. 2021 Jan;80(1):31-35.

doi: 10.1136/annrheumdis-2020-217344. Epub 2020 Oct 1.

EULAR definition of difficult-to-treat rheumatoid arthritis

György Nagy^{1

2}, Nadia Mt Roodenrijs³, Paco Mj Welsing³, Melinda Kedves⁴, Attila Hamar⁵, Marlies C van der Goes^{3

6}, Alison Kent⁷, Margot Bakkers⁸, Etienne Blaas³, Ladislav Senolt⁹, Zoltan Szekanecz⁵, Ernest Choy¹⁰, Maxime Dougados¹¹, Johannes Wg Jacobs³, Rinie Geenen¹², Hans Wj Bijlsma³, Angela Zink¹³, Daniel Aletaha¹⁴, Leonard Schoneveld¹⁵, Piet van Riel¹⁶, Loriane Gutermann¹⁷, Yeliz Prior¹⁸, Elena Nikiphorou¹⁹, Gianfranco Ferraccioli²⁰, Georg Schett²¹, Kimme L Hyrich^{22

23}, Ulf Mueller-Ladner²⁴, Maya H Buch^{22

23

25}, Iain B McInnes²⁶, Désirée van der Heijde^#²⁷, Jacob M van Laar^#³

Affiliations

¹ Department of Rheumatology, 3rd Department of Internal Medicine, Semmelweis University, Budapest, Hungary nagy.gyorgy2@med.semmelweis-univ.hu.
² Department of Genetics, Cell and Immunobiology, Semmelweis University, Budapest, Hungary.
³ Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands.
⁴ Department of Rheumatology, Bács-Kiskun County Hospital, Kecskemét, Hungary.
⁵ Department of Rheumatology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary.
⁶ Department of Rheumatology, Meander Medical Center, Amersfoort, the Netherlands.
⁷ Salisbury Foundation Trust NHS Hospital, Wiltshire, UK.
⁸ EULAR Standing Committee of People with Arthritis/Rheumatism in Europe (PARE), Zurich, Switzerland.
⁹ Department of Rheumatology, 1st Faculty of Medicine, Charles University and Institute of Rheumatology, Prague, Czech Republic.
¹⁰ CREATE Centre, Section of Rheumatology, School of Medicine, Division of Infection and Immunity, Cardiff University, Cardiff, UK.
¹¹ Université de Paris Department of Rheumatology - Hôpital Cochin. Assistance Publique - Hôpitaux de Paris INSERM (U1153): Clinical epidemiology and biostatistics, PRES Sorbonne Paris-Cité, Paris, France.
¹² Department of Psychology, Utrecht University, Utrecht, the Netherlands.
¹³ Epidemiology Unit, German Rheumatism Research Centre, and Rheumatology, Charité, University Medicine, Berlin, Germany.
¹⁴ Department of Internal Medicine III, Division of Rheumatology, Medical University of Vienna, Vienna, Austria.
¹⁵ Department of Rheumatology, Bravis Hospital, Roosendaal, the Netherlands.
¹⁶ Department of Rheumatic Diseases, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands.
¹⁷ Department of Pharmacy, Paris Descartes University, Hôpital Cochin, Assistance Publique Hôpitaux de Paris, Paris, France.
¹⁸ School of Health and Society, Centre for Health Sciences Research, University of Salford, Salford, UK.
¹⁹ Centre for Rheumatic Diseases, King's College London, London, UK.
²⁰ School of Medicine, Catholic University of the Sacred Heart, Rome, Italy.
²¹ Department of Internal Medicine 3, Rheumatology and Immunology, Friedrich-Alexander University of Erlangen-Nuremberg and Universitatsklinikum Erlangen, Erlangen, Germany.
²² NIHR Manchester Musculoskeletal Biomedical Research Unit, Central Manchester NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK.
²³ Centre for Musculoskeletal Research, School of Biological Sciences, Faculty of Biology, Medicine & Health, University of Manchester, Manchester, UK.
²⁴ Department of Rheumatology and Clinical Immunology, Justus-Liebig University Giessen, Kerckhoff Clinic Bad Nauheim, Bad Nauheim, Germany.
²⁵ Leeds Institute of Rheumatic & Musculoskeletal Medicine, University of Leeds, Leeds, UK.
²⁶ Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, UK.
²⁷ Department of Rheumatology, Leiden University Medical Center, Leiden, the Netherlands.

^# Contributed equally.

PMID: 33004335
PMCID: PMC7788062
DOI: 10.1136/annrheumdis-2020-217344

EULAR definition of difficult-to-treat rheumatoid arthritis

György Nagy et al. Ann Rheum Dis. 2021 Jan.

. 2021 Jan;80(1):31-35.

doi: 10.1136/annrheumdis-2020-217344. Epub 2020 Oct 1.

Authors

Affiliations

¹ Department of Rheumatology, 3rd Department of Internal Medicine, Semmelweis University, Budapest, Hungary nagy.gyorgy2@med.semmelweis-univ.hu.
² Department of Genetics, Cell and Immunobiology, Semmelweis University, Budapest, Hungary.
³ Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands.
⁴ Department of Rheumatology, Bács-Kiskun County Hospital, Kecskemét, Hungary.
⁵ Department of Rheumatology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary.
⁶ Department of Rheumatology, Meander Medical Center, Amersfoort, the Netherlands.
⁷ Salisbury Foundation Trust NHS Hospital, Wiltshire, UK.
⁸ EULAR Standing Committee of People with Arthritis/Rheumatism in Europe (PARE), Zurich, Switzerland.
⁹ Department of Rheumatology, 1st Faculty of Medicine, Charles University and Institute of Rheumatology, Prague, Czech Republic.
¹⁰ CREATE Centre, Section of Rheumatology, School of Medicine, Division of Infection and Immunity, Cardiff University, Cardiff, UK.
¹¹ Université de Paris Department of Rheumatology - Hôpital Cochin. Assistance Publique - Hôpitaux de Paris INSERM (U1153): Clinical epidemiology and biostatistics, PRES Sorbonne Paris-Cité, Paris, France.
¹² Department of Psychology, Utrecht University, Utrecht, the Netherlands.
¹³ Epidemiology Unit, German Rheumatism Research Centre, and Rheumatology, Charité, University Medicine, Berlin, Germany.
¹⁴ Department of Internal Medicine III, Division of Rheumatology, Medical University of Vienna, Vienna, Austria.
¹⁵ Department of Rheumatology, Bravis Hospital, Roosendaal, the Netherlands.
¹⁶ Department of Rheumatic Diseases, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands.
¹⁷ Department of Pharmacy, Paris Descartes University, Hôpital Cochin, Assistance Publique Hôpitaux de Paris, Paris, France.
¹⁸ School of Health and Society, Centre for Health Sciences Research, University of Salford, Salford, UK.
¹⁹ Centre for Rheumatic Diseases, King's College London, London, UK.
²⁰ School of Medicine, Catholic University of the Sacred Heart, Rome, Italy.
²¹ Department of Internal Medicine 3, Rheumatology and Immunology, Friedrich-Alexander University of Erlangen-Nuremberg and Universitatsklinikum Erlangen, Erlangen, Germany.
²² NIHR Manchester Musculoskeletal Biomedical Research Unit, Central Manchester NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK.
²³ Centre for Musculoskeletal Research, School of Biological Sciences, Faculty of Biology, Medicine & Health, University of Manchester, Manchester, UK.
²⁴ Department of Rheumatology and Clinical Immunology, Justus-Liebig University Giessen, Kerckhoff Clinic Bad Nauheim, Bad Nauheim, Germany.
²⁵ Leeds Institute of Rheumatic & Musculoskeletal Medicine, University of Leeds, Leeds, UK.
²⁶ Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, UK.
²⁷ Department of Rheumatology, Leiden University Medical Center, Leiden, the Netherlands.

^# Contributed equally.

PMID: 33004335
PMCID: PMC7788062
DOI: 10.1136/annrheumdis-2020-217344

Abstract

Background: Despite 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.

Objective: The 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.

Methods: The 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).

Results: The 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.

Conclusions: The proposed EULAR definition for difficult-to-treat RA can be used in clinical practice, clinical trials and can form a basis for future research.

Keywords: arthritis; immune system diseases; rheumatoid; synovitis.

PubMed Disclaimer

Conflict of interest statement

Competing interests: All participants provided declaration of interest, the individual declarations are attached as online supplemental file 2.

Comment in

Response to: 'Correspondence on 'EULAR definition of difficult-to-treat rheumatoid arthritis'' by Novella-Navarro et al.
Roodenrijs NMT, Welsing PMJ, van der Goes MC, Jacobs JW, van der Heijde D, van Laar JM, Nagy G. Roodenrijs NMT, et al. Ann Rheum Dis. 2023 Mar;82(3):e56. doi: 10.1136/annrheumdis-2020-219535. Epub 2020 Dec 4. Ann Rheum Dis. 2023. PMID: 33277239 No abstract available.
Correspondence on: 'EULAR definition of difficult-to-treat rheumatoid arthritis'.
Novella-Navarro M, Plasencia-Rodríguez C, Tornero C, Navarro-Compán V, Cabrera-Alarcón JL, Peiteado D, Nuño L, Monjo I, Franco-Gómez K, Villalba A, Balsa A. Novella-Navarro M, et al. Ann Rheum Dis. 2023 Mar;82(3):e55. doi: 10.1136/annrheumdis-2020-219500. Epub 2020 Dec 4. Ann Rheum Dis. 2023. PMID: 33277240 No abstract available.

References

1. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. . EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2019 update. Ann Rheum Dis 2020;79:685–99. 10.1136/annrheumdis-2019-216655 - DOI - PubMed
1. Singh JA, Saag KG, Bridges SL, et al. . 2015 American College of rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Rheumatol 2016;68:1–26. 10.1002/art.39480 - DOI - PubMed
1. Smolen JS, Breedveld FC, Burmester GR, et al. . Treating rheumatoid arthritis to target: 2014 update of the recommendations of an international Task force. Ann Rheum Dis 2016;75:3–15. 10.1136/annrheumdis-2015-207524 - DOI - PMC - PubMed
1. Kearsley-Fleet L, Davies R, De Cock D, et al. . Biologic refractory disease in rheumatoid arthritis: results from the British Society for rheumatology biologics register for rheumatoid arthritis. Ann Rheum Dis 2018;77:1405–12. 10.1136/annrheumdis-2018-213378 - DOI - PMC - PubMed
1. de Hair MJH, Jacobs JWG, Schoneveld JLM, et al. . Difficult-To-Treat rheumatoid arthritis: an area of unmet clinical need. Rheumatology 2018;57:1135–44. 10.1093/rheumatology/kex349 - DOI - PubMed

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EULAR definition of difficult-to-treat rheumatoid arthritis

Affiliations

EULAR definition of difficult-to-treat rheumatoid arthritis

Authors

Affiliations

Abstract

Conflict of interest statement

Comment in

References

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LinkOut - more resources

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Medical