Rheumatoid arthritis (RA) is an inflammatory autoimmune disease that causes pain, swelling and stiffness in the joints. It can also cause fatigue, and the underlying inflammation may affect other body systems.

A significant proportion of people with RA still have symptoms despite receiving treatment according to the current management recommendations. These people can be considered to have ’difficult-to-treat RA’.

EULAR prefers the term ‘difficult-to-treat’ for this group of people because it best captures the possible clinical scenarios. However, the concept is also still sometimes called severe, refractory, or drug-resistant RA. Managing these people can be challenging, and until now there have been no specific clinical recommendations. A task force was set up to develop new evidence-based points to consider for the management of people with difficult-to-treat RA. T

he group included rheumatologists and other health professionals and patient partners. Two overarching principles and 11 points were developed, alongside an algorithm that provides a visual summary of the suggested roadmap for people with difficult-to-treat RA.

The overarching principles stress that these points are specifically for people who meet the definition of difficult-totreat RA, and are underpinned by the main EULAR

recommendations. T

hey also state that the presence or absence of inflammation should be established to guide both pharmacological and nonpharmacological interventions. The specific management points focus on 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.

EULAR hopes that these points will provide a clinical roadmap to support healthcare professionals to deliver holistic management and more personalised treatment strategies for people with difficult-to-treat RA.