Heterogeneity of difficult-to-treat RA revealed
medwireNews: Difficult-to-treat rheumatoid arthritis (RA) encompasses several disease characteristics and issues, many of which are not covered by the current EULAR recommendations, indicates a survey of rheumatologists.
Nadia Roodenrijs (University Medical Center Utrecht, the Netherlands) and colleagues distributed an online questionnaire containing both multiple-choice and open questions, with the aim of identifying the disease characteristics of difficult-to-treat RA as well as any additional items missing from current management recommendations.
Of the 410 rheumatologists who completed the survey, 50% said they would characterize difficult-to-treat RA on the basis of disease activity, specifically, a Disease Activity Score at 28 joints based on the erythrocyte sedimentation rate (DAS28-ESR) of over 3.2 or the presence of signs suggesting active inflammatory disease with a DAS28-ESR of 3.2 or lower.
Other commonly selected characteristics were fatigue (42% of rheumatologists), failing treatment with at least two conventional DMARDs and at least two biologic or targeted DMARDs (48%), and the inability to taper the daily glucocorticoid dose to less than 5 mg (43%) or less than 10 mg (46%) prednisone equivalent for more than 1 year, irrespective of DMARD therapy.
And a further 169 respondents identified an additional 243 characteristics of difficult-to-treat RA, such as cardiovascular risk, malignancies, and vasculitis, which the researchers generally classified as “interfering comorbidities” and “extra-articular manifestations.”
These findings “show a wide variety in concepts of difficult-to-treat RA” and “underscore the difficulty in establishing an unambiguous concept of [the condition],” write the researchers in the Annals of the Rheumatic Diseases.
The surveyed rheumatologists also highlighted various clinically relevant situations that are not addressed by the current EULAR guidelines, including issues relating to pharmacologic management, pain syndromes, and pregnancy and lactation.
The authors note that a EULAR Task Force has been formed to develop recommendations for the comprehensive management of difficult-to-treat RA. “The results of this survey will fuel discussions on items to include in the management recommendations,” they say.
The preponderance of European rheumatologists completing the survey (96% of 385 respondents who gave the name of their country) means that “[these] results mainly reflect how difficult-to-treat RA is experienced in European countries,” comment Roodenrijs et al. They highlight limited access to diagnostic tests, rheumatologists, and DMARDs as additional factors that might arise in countries outside Europe.
By Catherine Booth
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