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 An 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 and D level 5 evidence or
inconsistent studies) and level of agreement (LoA, scale 0-10: 0 completely disagree
and 10 completely agree) of the PtCs were determined by the Task Force members. Results
Two overarching principles and 11 PtCs were defined concerning diagnostic confirmation
of RA, evaluation of inflammatory disease activity, pharmacological and non-pharmacological
interventions, treatment adherence, functional disability, pain, fatigue, goal setting
and self-efficacy and the impact of comorbidities. The SoR varied from level C to
level D. The mean LoA with the overarching principles and PtCs was generally high
(8.4-9.6). Conclusions These PtCs 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.
