What Is Difficult-to-Treat Rheumatoid Arthritis?

In spite of newer, better treatments for rheumatoid arthritis (RA), many people with the disease still have pain, swelling, stiffness, and loss of mobility. Their symptoms may progress over the years and cause severe health and economic results.1

To increase research and improve management of difficult-to-treat RA, the European League Against Rheumatism (EULAR) is developing recommendations. As a first step, in October 2020, EULAR published a proposed definition for difficult-to-treat RA.2

What is EULAR?

EULAR is an umbrella organization that represents scientists, health professionals, and people with arthritis and rheumatic diseases throughout Europe. EULAR aims to reduce the burden of rheumatic diseases on the individual and society.3

The EULAR steering committee conducted a survey among rheumatologists about the definition of difficult-to-treat RA. Rheumatologists are doctors who specialize in:4,5

  • Diseases that affect the joints, muscles, and bones
  • Autoimmune diseases, in which the immune system mistakenly attacks healthy tissue

The steering committee received 410 responses from 33 countries. Using survey results, the committee drafted a definition and appointed a task force to refine it. The task force consisted of rheumatologists, nurses, other health professionals, and people diagnosed with RA.3

How is difficult-to-treat RA defined?

Members of the EULAR taskforce agreed that 3 criteria must be met to be defined as difficult-to-treat RA: treatment failure history, active/symptomatic disease, and perception of clinical difficulty.2

Treatment failure history

This criteria outlines a progression:2

Active/symptomatic disease

This criteria list signs, of which 1 or more must be present to be defined as active disease:2

  • At least moderate disease activity, according to scientifically accepted measures, such as counts of the number of inflamed joints, a blood test that indicates body-wide inflammation, or an elevated score on a clinical assessment of RA severity
  • Imaging, biochemical markers, or symptoms indicating active disease. Symptoms may be joint-related or inflammation of blood vessels, eyes, kidneys, or the membrane around the heart.
  • Inability to taper steroid treatment without an increase in symptoms
  • Rapid progression visible on X-rays
  • Additional symptoms that reduce the quality of life

Perception of clinical difficulty

The rheumatologist or the person with RA considers the management of symptoms as a problem.2

Why is this definition important?

RA is the most common type of autoimmune arthritis. Worldwide, nearly 20 million people had RA in 2017, according to the World Health Organization’s Global Burden of Disease study.6,7

RA can occur at any age, but tends to strike between the ages of 20 and 40, usually a person’s most productive work years. Because of pain, joint damage, immobility, fatigue, and depression, RA reduces a person's quality of life. Within 10 years after RA’s onset, at least 50 percent of people with RA in developed countries are not able to hold down a full-time job.8,9

Studies showed that RA contributes to the economic burden on both people who have RA and society as a whole. In the United States, Canada, and the United Kingdom, work-related disabilities and sick leaves cost the economy billions of dollars.10

New approaches to treatment and research

Having an agreed-upon definition of difficult-to-treat RA will help EULAR develop a new management approach for people in whom current recommendations do not achieve remission or lower disease activity.2

Besides helping with disease management now, the definition will provide consistent recognition of a group of people with similar disease for clinical trials. Participation of people with RA in clinical research is one of the best ways to advance new knowledge about RA and contribute to the development of new treatments.1,2

Consistent definition across Europe will make it easier for scientists in Europe and other countries to conduct cooperative, coordinated research. Worldwide integration of research in labs, clinics, and the community will bring better and faster results in understanding causes, prevention, and future cures for RA.3

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