From the Journals

Difficult-to-treat RA remains difficult to define



Active disease, failure of disease-modifying antirheumatic drug therapy, and an inability to taper glucocorticoid treatment are the main characteristics of difficult-to-treat RA, according to results of a survey of mostly European rheumatologists that also revealed a wide variation in views on the factors that contribute to the concept.


Some of the issues that survey respondents considered clinically relevant in difficult-to-treat RA are not covered by current EULAR management recommendations, Nadia M.T. Roodenrijs, of University Medical Center Utrecht, the Netherlands, and her colleagues noted in a study published online in Annals of the Rheumatic Diseases.

The investigators set out to determine what a range of rheumatologists from different countries considered to be the key characteristics of difficult-to-treat RA, which has an estimated prevalence of 5%-20%, depending on the criteria used. They also sought to identify the issues relating to work-up and management that were not covered by the current EULAR recommendations.

The online survey contained four multiple choice questions that asked about the necessity of incorporating disease activity level, fatigue, number of disease-modifying antirheumatic drugs (DMARDs) that failed, and the inability to taper glucocorticoids into the concept of difficult-to-treat RA. The survey also asked three open questions seeking additional clinically relevant views on difficult-to-treat RA.

A total of 410 respondents from 33 countries (96% European) completed the survey, which was sent to rheumatologists through the Emerging EULAR Network. Overall, half of the respondents selected “disease activity score assessing 28 joints using erythrocyte sedimentation rate [DAS28-ESR] greater than 3.2 or the presence of signs suggestive of active inflammatory disease activity with a DAS28-ESR of 3.2 or less” as characteristics of difficult-to-treat RA. About 42% of respondents included fatigue as a characteristic and 48% selected failure to two or more conventional DMARDs and two or more biological/targeted synthetic DMARDs. Furthermore, 89% of respondents identified the inability to taper glucocorticoids below 5 mg or 10 mg prednisone equivalent daily to be a characteristic of difficult-to-treat RA.

Other clinically important issues identified by the respondents as currently missing from EULAR management recommendations included interfering comorbidities, especially cardiovascular disease, infection, and malignancy; extra-articular manifestations; and polypharmacy.

“The results of this survey underscore the difficulty in establishing an unambiguous concept of difficult-to-treat RA, which is seen as a heterogeneous condition not fully covered by EULAR recommendations,” the authors wrote.

The authors noted that their findings would help fuel discussion on the issues to include in the management recommendations for difficult-to-treat RA currently under consideration by a recently established EULAR task force.

The study was not funded with a specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Some of the authors reported receiving fees from several pharmaceutical countries.

SOURCE: Roodenrijs NMT et al. Ann Rheum Dis. 2018 Sep 7. doi: 10.1136/annrheumdis-2018-213687.

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