The present study was not able to recognize any new characteristic feature or issues in the management of difficult –to-treat RA.  A more detailed survey is still needed to study the management of difficult-to-treat RA further and the recently established EULAR Task Force will explore the management of difficult-to-treat RA.

Patients with difficult-to-treat RA remain symptomatic despite treatment as per the current European League Against Rheumatism (EULAR) management recommendations. These aim at early phases of the disease and pharmacological management. The researchers tried to identify the characteristics of difficult-to-treat RA and issues in its management that are not covered by the current management recommendations.

Rheumatologists had to go through an international survey which contained MCQs about the features of difficult-to-treat RA. Additional items to be addressed and items missing in the current management recommendations were recognised using open questions.

Overall, 410 respondents completed the survey out of which 50% selected disease activity score examining 28 joints >3.2 OR presence of signs indicative of active disease as features of difficult-to-treat RA; 42% selected fatigue; 48% selected failure to ≥2 conventional synthetic DMARDs AND ≥2 biological/targeted synthetic DMARDs; 89% selected inability to attenuate glucocorticoids below 5 mg or 10 mg prednisone equivalent daily. Interfering comorbidities, extra-articular manifestations and polypharmacy were recognised as essential issues absent in current management recommendations.

There is wide variation in the theory of difficult-to-treat RA. Current EULAR recommendations do not address several important issues regarding these patients.