Difficult to treat

Rheumatoid Arthritis


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EULAR definition of difficult-to-treat rheumatoid arthritis

Criteria 1:

Failure of ≥2 b/tsDMARDs (with different mechanisms of action) after failing csDMARD therapy (unless contraindicated).
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Criteria 2:

Signs suggestive of active/progressive disease, defined as:

At least moderate disease activity (according to validated composite measures including joint counts, for example, DAS28-ESR>3.2 or CDAI>10)
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Signs (including acute phase reactants and imaging) and/ or symptoms suggestive of active disease (joint related or other)
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Inability to taper glucocorticoid treatment (below 7.5 mg/ day prednisone or equivalent).
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Rapid radiographic progression (with or without signs of active disease)

Rapid radiographic progression: change in van der Heijde-modified Sharp score ≥5 points at 1 year

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Well-controlled disease according to above standards, but still having RA symptoms that are causing a reduction in quality of life.
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Criteria 3:

The management of signs and/or symptoms is perceived as problematic by the rheumatologist and/or the patient.
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The tool is for educational use only, is not meant to be a substitute for professional advice and should not be used for medical diagnosis and/or medical treatment.


Nagy G, Roodenrijs NMT, Welsing PM, Kedves M, Hamar A, van der Goes MC, Kent A, Bakkers M, Blaas E, Senolt L, Szekanecz Z, Choy E, Dougados M, Jacobs JW, Geenen R, Bijlsma HW, Zink A, Aletaha D, Schoneveld L, van Riel P, Gutermann L, Prior Y, Nikiphorou E, Ferraccioli G, Schett G, Hyrich KL, Mueller-Ladner U, Buch MH, McInnes IB, van der Heijde D, van Laar JM. EULAR definition of difficult-to-treat rheumatoid arthritis. Ann Rheum Dis. 2021 Jan;80(1):31-35. doi: 10.1136/annrheumdis-2020-217344. Epub 2020 Oct 1. PMID: 33004335; PMCID: PMC7788062.

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