You are here

Article Text

Article menu

Download PDFPDF

XML
Recommendation
EULAR definition of difficult-to-treat rheumatoid arthritis
  1. György Nagy1,2,
  2. Nadia MT Roodenrijs3,
  3. Paco MJ Welsing3,
  4. Melinda Kedves4,
  5. Attila Hamar5,
  6. Marlies C van der Goes3,6,
  7. Alison Kent7,
  8. Margot Bakkers8,
  9. Etienne Blaas3,
  10. Ladislav Senolt9,
  11. Zoltan Szekanecz5,
  12. Ernest Choy10,
  13. Maxime Dougados11,
  14. Johannes WG Jacobs3,
  15. Rinie Geenen12,
  16. Hans WJ Bijlsma3,
  17. Angela Zink13,
  18. Daniel Aletaha14,
  19. Leonard Schoneveld15,
  20. Piet van Riel16,
  21. Loriane Gutermann17,
  22. Yeliz Prior18,
  23. Elena Nikiphorou19,
  24. Gianfranco Ferraccioli20,
  25. Georg Schett21,
  26. Kimme L Hyrich22,23,
  27. Ulf Mueller-Ladner24,
  28. Maya H Buch22,23,25,
  29. Iain B McInnes26,
  30. Désirée van der Heijde27,
  31. Jacob M van Laar3
  1. 1 Department of Rheumatology, 3rd Department of Internal Medicine, Semmelweis University, Budapest, Hungary
  2. 2 Department of Genetics, Cell and Immunobiology, Semmelweis University, Budapest, Hungary
  3. 3 Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
  4. 4 Department of Rheumatology, Bács-Kiskun County Hospital, Kecskemét, Hungary
  5. 5 Department of Rheumatology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
  6. 6 Department of Rheumatology, Meander Medical Center, Amersfoort, the Netherlands
  7. 7 Salisbury Foundation Trust NHS Hospital, Wiltshire, UK
  8. 8 EULAR Standing Committee of People with Arthritis/Rheumatism in Europe (PARE), Zurich, Switzerland
  9. 9 Department of Rheumatology, 1st Faculty of Medicine, Charles University and Institute of Rheumatology, Prague, Czech Republic
  10. 10 CREATE Centre, Section of Rheumatology, School of Medicine, Division of Infection and Immunity, Cardiff University, Cardiff, UK
  11. 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. 12 Department of Psychology, Utrecht University, Utrecht, the Netherlands
  13. 13 Epidemiology Unit, German Rheumatism Research Centre, and Rheumatology, Charité, University Medicine, Berlin, Germany
  14. 14 Department of Internal Medicine III, Division of Rheumatology, Medical University of Vienna, Vienna, Austria
  15. 15 Department of Rheumatology, Bravis Hospital, Roosendaal, the Netherlands
  16. 16 Department of Rheumatic Diseases, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands
  17. 17 Department of Pharmacy, Paris Descartes University, Hôpital Cochin, Assistance Publique Hôpitaux de Paris, Paris, France
  18. 18 School of Health and Society, Centre for Health Sciences Research, University of Salford, Salford, UK
  19. 19 Centre for Rheumatic Diseases, King's College London, London, UK
  20. 20 School of Medicine, Catholic University of the Sacred Heart, Rome, Italy
  21. 21 Department of Internal Medicine 3, Rheumatology and Immunology, Friedrich-Alexander University of Erlangen-Nuremberg and Universitatsklinikum Erlangen, Erlangen, Germany
  22. 22 NIHR Manchester Musculoskeletal Biomedical Research Unit, Central Manchester NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
  23. 23 Centre for Musculoskeletal Research, School of Biological Sciences, Faculty of Biology, Medicine & Health, University of Manchester, Manchester, UK
  24. 24 Department of Rheumatology and Clinical Immunology, Justus-Liebig University Giessen, Kerckhoff Clinic Bad Nauheim, Bad Nauheim, Germany
  25. 25 Leeds Institute of Rheumatic & Musculoskeletal Medicine, University of Leeds, Leeds, UK
  26. 26 Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, UK
  27. 27 Department of Rheumatology, Leiden University Medical Center, Leiden, the Netherlands
  1. Correspondence to Professor György Nagy, Department of Rheumatology, Semmelweis University, Budapest, Árpád fejedelem útja 7., 1023, Hungary; nagy.gyorgy2{at}med.semmelweis-univ.hu

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.

  • arthritis
  • rheumatoid
  • synovitis
  • immune system diseases
http://creativecommons.org/licenses/by-nc/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

https://doi.org/10.1136/annrheumdis-2020-217344

Statistics from Altmetric.com

    Request Permissions

    If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

    View Full Text

    Footnotes

    • DvdH and JMvL are joint senior authors.

    • Handling editor David S Pisetsky

    • Twitter @YelizPrior, @ElenaNikiUK

    • DvdH and JMvL contributed equally.

    • Contributors GN wrote the first draft of the manuscript, with the help from DvdH, NMTR, PMJW, IBM and JMvL. All authors participated in the work of the Task Force and provided coauthor contribution to the manuscript. All authors read and approved the final manuscript.

    • Funding This study was funded by European League Against Rheumatism.

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

    • Patient and public involvement Patients and/or the public were involved in the design, or conduct, or reporting, or dissemination plans of this research. Refer to the Methods section for further details.

    • Patient consent for publication Not required.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data availability statement All data relevant to the study are included in the article or uploaded as online supplemental file 1.