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EULAR points to consider for the management of difficult-to-treat rheumatoid arthritis

Nagy, G; Roodenrijs, NMT; Welsing, PMJ; Kedves, M; Hamar, A; van der Goes, MC; Kent, A; Bakkers, M; Pchelnikova, P; Blaas, E; Senolt, L; Szekanecz, Z; Choy, E; Dougados, M; Jacobs, JWG; Geenen, R; Bijlsma, JWJ; Zink, A; Aletaha, D; Schoneveld, L; van Riel, P; Dumas, S; Prior, Y; Nikiphorou, E; Ferraccioli, G; Schett, G; Hyrich, K; Müller-Ladner, U; Buch, MH; McInnes, IB; van der Heijde, D; Van Laar, JM


G Nagy

NMT Roodenrijs

PMJ Welsing

M Kedves

A Hamar

MC van der Goes

A Kent

M Bakkers

P Pchelnikova

E Blaas

L Senolt

Z Szekanecz

E Choy

M Dougados

JWG Jacobs

R Geenen

JWJ Bijlsma

A Zink

D Aletaha

L Schoneveld

P van Riel

S Dumas

E Nikiphorou

G Ferraccioli

G Schett

K Hyrich

U Müller-Ladner

MH Buch

IB McInnes

D van der Heijde

JM Van Laar


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: A 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, D level 5 evidence or inconsistent studies) and level of agreement (LoA,
scale 0-10: 0 completely disagree, 10 completely agree) of the PtCs were determined by the Task
Force members.
Results: Two overarching principles and eleven PtCs were defined concerning diagnostic
confirmation of RA, evaluation of inflammatory disease activity, pharmacological and nonpharmacological interventions, treatment adherence, functional disability, pain, fatigue, goal
setting and self-efficacy and the impact of comorbidities. The SoR varied from level C to D. The
mean LoA with the overarching principles and PtCs was generally high (8.4-9.6).
Conclusions: These points to consider 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.


Nagy, G., Roodenrijs, N., Welsing, P., Kedves, M., Hamar, A., van der Goes, M., …Van Laar, J. (2021). EULAR points to consider for the management of difficult-to-treat rheumatoid arthritis. Annals of the Rheumatic Diseases,

Journal Article Type Article
Acceptance Date Jul 23, 2021
Online Publication Date Aug 18, 2021
Publication Date Aug 18, 2021
Deposit Date Jul 26, 2021
Publicly Available Date Sep 1, 2021
Journal Annals of the Rheumatic Diseases (ARD)
Print ISSN 0003-4967
Electronic ISSN 1468-2060
Publisher BMJ Publishing Group
Publisher URL
Related Public URLs
Additional Information Access Information : © Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use.
Funders : European Alliance of Associations for Rheumatology
Projects : EULAR Task Force on development of EULAR recommendations for the comprehensive management of difficult-to-treat rheumatoid arthritis (D2T RA)
Grant Number: N/A


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