Table 1

EULAR PtCs for the management of D2T RA

LoE22 SoR22 LoA mean (SD)≥8/10 (%)
Overarching principles
AThese PtCs pertain to patients who fulfil the definition of D2T RA and are underpinned by the EULAR recommendations for the management of RA, including the overarching principles.2 17 NANA9.6 (1.0)97
BThe presence or absence of inflammation should be established to guide pharmacological and non-pharmacological interventions.NANA9.5 (1.3)91
1If a patient has a presumed D2T RA, the possibility of misdiagnosis and/or the presence of a coexistent mimicking disease* should be considered as a first step.5D9.3 (1.2)91
2Where there is a doubt on the presence of inflammatory activity based on clinical assessment and composite indices, US may be considered for this evaluation.4C9.2 (1.4)91
3Composite indices and clinical evaluation should be interpreted with caution in the presence of comorbidities in particular obesity and fibromyalgia§ as these may directly heighten inflammatory activity and/or overestimate disease activity. 5
9.2 (1.3)88
4Treatment adherence should be discussed and optimised within the process of shared decision-making.5D9.5 (1.0)97
5After failure of a second or subsequent b/tsDMARD and particularly after two TNFi failures§ treatment with a b/tsDMARD with a different target should be considered. 4
9.2 (1.3)94
6If a third or subsequent b/tsDMARD is being considered, the maximum dose, as found effective and safe in appropriate testing, should be used.3C8.4 (1.8)75
7Comorbidities† that impact quality of life either independently or by limiting RA treatment options should be carefully considered and managed.5D9.3 (0.8)97
8In patients with concomitant HBV/HCV infection, b/tsDMARDs can be used and concomitant antiviral prophylaxis or treatment should be considered in close collaboration with the hepatologist§. 4
8.9 (1.4)88
9In addition to pharmacological treatment, non-pharmacological interventions (ie, exercise, psychological§, educational and self-management interventions) should be considered to optimise management of functional disability, pain and fatigue. 3
9.4 (1.2)97
10Appropriate education and support should be offered to patients to directly inform their choices of treatment goals and management.4C9.4 (1.2)97
11Consider offering self-management programmes, relevant education and psychological interventions to optimise patient’s ability to manage their disease confidently (ie, self-efficacy).3C9.1 (1.7)91
  • In case the LoE and SoR differed for different items within a PtC, differences in LoE and SoR are shown using the symbols‡ and §.

  • *Relevant mimicking diseases, for instance, crystal arthropathies, polymyalgia rheumatica, psoriatic arthritis, spondyloarthritis, Still’s disease, SLE, Rhupus syndrome, vasculitis, idiopathic inflammatory myopathies, RS3PE, reactive arthritis (eg, parvo B19, Rubella, Whipple’s disease, HBV and HCV infections), paraneoplastic syndromes, osteoarthritis and fibromyalgia.

  • †Relevant comorbidities: for instance, infections, malignancies, polymyalgia rheumatica and osteoarthritis, and consequences of longstanding destructive disease such as subluxations and joint dislocations.

  • b/tsDMARD, biological and targeted synthetic disease-modifying antirheumatic drugs; D2T, difficult-to-treat; EULAR, European Alliance of Associations for Rheumatology; HBV, hepatitis B virus; HCV, hepatitis C virus; LoA, levels of agreement; LoE, level of evidence (according to the standards of the Oxford Centre for Evidence-Based Medicine); NA, not applicable; PtCs, points to consider; RA, rheumatoid arthritis; RS3PE, remitting symmetric seronegative synovitis and pitting oedema; SLE, systemic lupus erythematosus; SoR, strengths of recommendations (according to the standards of the Oxford Centre for Evidence-Based Medicine); TNFi, tumour necrosis factor inhibitor; US, ultrasonography.