EULAR: Difficult-to-treat rheumatoid arthritis may call for psychological therapies
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Providers should consider nonpharmacologic therapies, including exercise, education and psychological and self-management interventions, in cases of difficult-to-treat rheumatoid arthritis, according to new EULAR “points to consider.”
“[Approximately] 0.5-1% of the population has rheumatoid arthritis and up to 30% of RA patients may have difficult-to-treat disease,” György Nagy, MD, PhD, DSc, of Semmelweis University in Budapest, Hungary, told Healio Rheumatology. “This means that, in the United States, the number of patients with difficult-to-treat RA might be up to 1 million. All rheumatologists treat RA patients, as well as several general practitioners and internists.”
Writing in the Annals of the Rheumatic Diseases, Nagy and colleagues added that “optimal management of these patients poses a significant challenge in clinical practice,” and “no specific guidance has been developed for the management of this complex patient population.”
To develop points to consider for the management of difficult-to-treat RA, Nagy and colleagues formed a 34-member EULAR task force, including 26 rheumatologists, patient partners and health professionals with rheumatology experience. Members of the task force performed two systematic literature reviews to address clinical questions regrading diagnostic challenges and treatment strategies.
Also, as an initial step, the task force endeavored to establish a uniform definition of difficult-to-treat RA. Guided by an international survey and a literature review, a steering committee drew up a first draft, which was later discussed and amended by the full task force. The final definition was approved via a vote.
Later, based on the gathered evidence and expert opinion, task force members drafted a series of overarching principles and points to consider, and voted on their strength and level of agreement.
According to members of the task force, three criteria must be met for a case to be considered difficult-to-treat RA:
- Treatment based on EULAR recommendations and failure of at least two biologic or targeted synthetic disease-modifying antirheumatic drugs, with different mechanisms of action, after failing conventional synthetic DMARDs, unless contraindicated;
- Evidence of active or progressive disease, defined as at least one of the following:
- At least moderate disease activity based on validated composite measures including joint counts;
- Signs, such as acute phase reactants and imaging, or symptoms of active disease, whether joint related or other;
- Inability to taper glucocorticoids below 7.5 mg/day prednisone or equivalent; and
- Well-controlled disease that nonetheless demonstrates RA symptoms that cause a reduction in quality of life.
- Sign or symptom management is perceived by the patient or provider as problematic.
In all, Nagy and colleagues developed and approved two overarching principles and 11 points to consider. The overarching principles state that the points to consider apply only to patients who meet the criteria for difficult-to-treat disease, and are “underpinned by the EULAR recommendations for the management of RA.” In addition, providers should establish the presence or absence of inflammation to guide treatment.
According to the points to consider, providers should consider the possibility of a misdiagnosis — or the presence of a coexistent mimicking disease — as a first step. Providers may consider using ultrasound in cases where there is doubt regarding the presence of inflammation based on clinical assessment and composite indices. Indeed, composite indices and clinical assessments should be read with caution in the presence of comorbidities, the authors wrote, particularly obesity and fibromyalgia. According to the task force, these conditions may directly increase inflammation or overestimate disease activity.
Further, patients and providers should discuss and improve treatment adherence through a process of shared decision-making. Following the failure of a second or subsequent biologic or targeted synthetic DMARD, and especially after the failure of two TNF inhibitors, providers should consider treatment with a biologic or targeted synthetic DMARD aimed at a different target. If a third or subsequent biologic or targeted synthetic DMARD is considered, the maximum safe, effective dose should be used.
Other points to consider include:
- Providers should carefully consider and manage comorbidities that impact quality of life, either directly or through limiting treatment;
- In patients with concomitant hepatitis B or C infection, providers can use biologic or targeted synthetic DMARDs, and antiviral prophylaxis or treatment should be considered under collaboration with a hepatologist;
- Nonpharmacological therapies, including exercise, psychological treatment, education and self-management interventions, should be considered to improve functional disability, pain and fatigue;
- Patients should be offered education and support that informs their choices of treatment goals and management; and
- Providers should consider offering patients self-management programs, education and psychological treatment to improve their ability to confidently manage their disease.
“We created the definition of difficult-to-treat RA and we provide a clinical roadmap, including both pharmacological and non-pharmacological therapy, for to treatment of these patients,” Nagy said. “Hopefully our algorithm will be useful in daily clinical practice.
“No previous guidelines or recommendations include even a similar approach,” he added. “This is the initiative of EULAR, and all methodological considerations were carefully followed. This is the product of an international and multidisciplinary task force.”
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