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, Marlies C Van der goes, Alison Kent, Margot Bakkers, Polina Pchelnikova, Etienne Blaas, Ladislav Senolt, Zoltan Szekanecz, Ernest H Choy, Maxime Dougados, Johannes Wg Jacobs, Rinie Geenen, Johannes Wj Bijlsma, Angela Zink, Daniel Aletaha, Leonard SchoneveldPiet Van riel, Sophie Dumas, Yeliz Prior, Elena Nikiphorou, Gianfranco Ferraccioli, Georg Schett, Kimme L Hyrich, Ulf Mueller-Ladner, Maya H Buch, Iain B Mcinnes, Désirée Van der heijde, Jacob M Van laar

Research output: Contribution to journalArticlepeer-review

110 Citations (Scopus)


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 An 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 and D level 5 evidence or inconsistent studies) and level of agreement (LoA, scale 0–10: 0 completely disagree and 10 completely agree) of the PtCs were determined by the Task Force members.

Results Two overarching principles and 11 PtCs were defined concerning diagnostic confirmation of RA, evaluation of inflammatory disease activity, pharmacological and non-pharmacological interventions, treatment adherence, functional disability, pain, fatigue, goal setting and self-efficacy and the impact of comorbidities. The SoR varied from level C to level D. The mean LoA with the overarching principles and PtCs was generally high (8.4–9.6).

Conclusions These PtCs 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
Pages (from-to)20-33
Number of pages14
JournalAnnals of the Rheumatic Diseases
Issue number1
Early online date18 Aug 2021
Publication statusPublished - 4 Jan 2022


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