EULAR definition of difficult-to-treat rheumatoid arthritis leaves ‘some holes’
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SAN DIEGO — The official EULAR definition of difficult-to-treat rheumatoid arthritis does not fully account for the problems the disease can present, according to a presenter at the Congress of Clinical Rheumatology West.
Published in 2021, the EULAR definition states, in part, that patients who have been treated according to EULAR recommendations and have failed two or more biologic or traditional synthetic disease-modifying antirheumatic drugs (DMARDs), after failing a conventional synthetic DMARD, are considered to have difficult to treat RA.
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“I think there is a good start here, but there are some holes in this definition that I think you are likely to agree with,” Jeffrey Sparks, MDMMSc, of Harvard Medical School and Brigham and Women’s Hospital, in Boston, told attendees.
The first argument Sparks raised is that patients who fail so many therapies are likely to be well along on the disease course.
“They have had to fail multiple mechanisms of action,” he said. “That also means they had to adhere to them. It also means that they had insurance coverage.”
Sparks additionally argued that the definition assumes that the patient has RA and is not experiencing similar symptoms of another disease. This is especially a concern in patients who are seronegative, he said.
“The second assumption is that the patients actually took DMARDs,” Sparks said. “And, of course, failure is not objective. There are many reasons to fail — there are degrees of failure.”
The second portion of the definition, meanwhile, involves signs of progressing disease. These factors include moderate disease activity, an inability to taper glucocorticoids, rapid radiographic progression and, finally, disease that is well-managed but still leads to reduced quality of life for patients.
“Every bullet point here has some holes in it that allows patients without active RA to fit the definition,” Sparks said. “Validated measures have subjective components.”
Specifically, he noted that patients who might not trigger moderate disease activity criteria may still demonstrate active disease in isolated joints.
Additionally, the subjective nature of symptoms makes it difficult to determine if a patient is in actual active disease, according to Sparks.
“Symptoms are subjective by definition, so I think that is a bigger issue related to active, progressive disease,” he said.
Sparks then recalled the difficulty of getting some patients to successfully taper their glucocorticoids.
“As you all probably know, there are some patients that just really like prednisone, and try as you might, they are really kind of self-treating at this point,” he said. “To call this difficult-to-treat RA — there is something difficult about it, but again, I am not sure it is all due to recalcitrant, active RA.”
Sparks also noted patients with well-controlled disease who still demonstrate persistent quality of life concerns. These patients could be experiencing disease unrelated to RA, he said.
The last part of the EULAR definition states that if the rheumatologist or patient believes the management of symptoms is problematic, it may fit the definition of difficult-to-treat RA.
“I do not think this is really specific to a pathoetiologic process specific to RA,” Sparks said.
“Having said that, this is certainly a start for research criteria, and it points us in a direction.”
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Sparks J. Difficult to treat rheumatoid arthritis. Presented at the Congress of Clinical Rheumatology West; Sept. 7-10, 2023 (hybrid meeting).
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