Rheumatoid arthritis (RA) remains symptomatic in some patients after several treatment cycles. European League Against Rheumatism (EULAR) management recommendations considered these patients as difficult-to treat. Nadia M T Roodenrijs and colleagues conducted an analysis to address characteristics of difficult-to-treat RA and associated options for its management which are not incorporated by recent management recommendations.

For this, an international survey was directed in the rheumatologists involving multiple-choice questions on difficult-to-treat RA features. Additional and missing items in the present management recommendations were identified through open questions.

Among 410 respondents, approximately 50% of patients selected measures of active disease and DAS-28 as characteristic of difficult-to-treat RA. However  89% selected inability to taper glucocorticoids below 5 mg or 10 mg prednisone equivalent daily, 42% selected fatigue and 48% selected failure to ≥2 conventional DMARDs and ≥2 biological/targeted synthetic DMARDs as the essential characteristics.

The critical problems that noticed to be missing in the current management recommendations were extra-articular indications, polypharmacy and interfering comorbidities. The vast differences were seen in the theories of difficult-to-treat RA. Current EULAR recommendations do not address several essential issues concerning these patients.