EULAR points to consider for the management of difficult-to-treat rheumatoid arthritis

György Nagy, Nadia M T Roodenrijs, Paco M J Welsing, Melinda Kedves, Attila Hamar, der Goes MC van, Alison Kent, Margot Bakkers, Polina Pchelnikova, Etienne Blaas, Ladislav Senolt, Zoltan Szekanecz, Ernest Choy, Maxime Dougados, Johannes W G Jacobs, Rinie Geenen, Johannes W.J Bijlsma, Angela Zink, Daniel Aletaha, Leonard SchoneveldPiet van Riel, Sophie Dumas, Yeliz Prior, Elena Nikiphorou, Gianfranco Ferraccioli, Georg Schett, Kimme Hyrich, Ulf Müller-Ladner, Maya Buch, Iain B McInnes, Desiree van der Heijde, van Laar Jacob

Research output: Contribution to journalArticlepeer-review


Objective: To develop evidence-based European Alliance of Associations for Rheumatology
(EULAR) points to consider (PtCs) for the management of difficult-to-treat rheumatoid arthritis
(D2T RA).
Methods: A EULAR Task Force was established comprising 34 individuals: 26 rheumatologists,
patient partners and rheumatology experienced health professionals. Two systematic literature
reviews addressed clinical questions around diagnostic challenges, and pharmacological and
non-pharmacological therapeutic strategies in D2T RA. PtCs were formulated based on the
identified evidence and expert opinion. Strength of recommendations (SoR, scale A-D: A typically
consistent level 1 studies, D level 5 evidence or inconsistent studies) and level of agreement (LoA,
scale 0-10: 0 completely disagree, 10 completely agree) of the PtCs were determined by the Task
Force members.
Results: Two overarching principles and eleven PtCs were defined concerning diagnostic
confirmation of RA, evaluation of inflammatory disease activity, pharmacological and nonpharmacological
interventions, treatment adherence, functional disability, pain, fatigue, goal
setting and self-efficacy and the impact of comorbidities. The SoR varied from level C to D. The
mean LoA with the overarching principles and PtCs was generally high (8.4-9.6).
Conclusions: These points to consider for D2T RA can serve as a clinical roadmap to support
healthcare professionals and patients to deliver holistic management and more personalised
pharmacological and non-pharmacological therapeutic strategies. High-quality evidence was
scarce. A research agenda was created to guide future research.
Original languageEnglish
JournalAnnals of the rheumatic diseases
Publication statusPublished - 2021


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