EULAR definition of difficult-to-treat rheumatoid arthritis

G. Nagy, N.M. Roodenrijs, P.M. Welsing, M. Kedves, A. Hamar, M.C. van der Goes, A. Kent, M. Bakkers, E. Blaas, L. Senolt, Z. Szekanecz, E. Choy, M. Dougados, J.W. Jacobs, R. Geenen, H.W. Bijlsma, A. Zink, D. Aletaha, L. Schoneveld, P. van RielL. Gutermann, Y. Prior, E. Nikiphorou, G. Ferraccioli, G. Schett, K.L. Hyrich, U. Mueller-Ladner, M.H. Buch, I.B. McInnes, D. van der Heijde, J.M. van Laar

Research output: Contribution to journalArticleAcademicpeer-review


BACKGROUND: Despite treatment according to the current management recommendations, a significant proportion of patients with rheumatoid arthritis (RA) remain symptomatic. These patients can be considered to have 'difficult-to-treat RA'. However, uniform terminology and an appropriate definition are lacking.

OBJECTIVE: The Task Force in charge of the "Development of EULAR recommendations for the comprehensive management of difficult-to-treat rheumatoid arthritis" aims to create recommendations for this underserved patient group. Herein, we present the definition of difficult-to-treat RA, as the first step.

METHODS: The Steering Committee drafted a definition with suggested terminology based on an international survey among rheumatologists. This was discussed and amended by the Task Force, including rheumatologists, nurses, health professionals and patients, at a face-to-face meeting until sufficient agreement was reached (assessed through voting).

RESULTS: The following three criteria were agreed by all Task Force members as mandatory elements of the definition of difficult-to-treat RA: (1) Treatment according to European League Against Rheumatism (EULAR) recommendation and failure of ≥2 biological disease-modifying antirheumatic drugs (DMARDs)/targeted synthetic DMARDs (with different mechanisms of action) after failing conventional synthetic DMARD therapy (unless contraindicated); (2) presence of at least one of the following: at least moderate disease activity; signs and/or symptoms suggestive of active disease; inability to taper glucocorticoid treatment; rapid radiographic progression; RA symptoms that are causing a reduction in quality of life; and (3) the management of signs and/or symptoms is perceived as problematic by the rheumatologist and/or the patient.

CONCLUSIONS: The proposed EULAR definition for difficult-to-treat RA can be used in clinical practice, clinical trials and can form a basis for future research.

Original languageEnglish
Pages (from-to)31-35
Number of pages5
JournalAnnals of the Rheumatic Diseases
Issue number1
Publication statusPublished - Jan 2021


  • arthritis
  • immune system diseases
  • rheumatoid
  • synovitis


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