{"id":1022,"date":"2021-08-18T10:06:27","date_gmt":"2021-08-18T10:06:27","guid":{"rendered":"https:\/\/blogs.bmj.com\/rheumsummaries\/?p=1022"},"modified":"2022-05-30T15:26:38","modified_gmt":"2022-05-30T15:26:38","slug":"managing-difficult-to-treat-arthritis","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/rheumsummaries\/2021\/08\/18\/managing-difficult-to-treat-arthritis\/","title":{"rendered":"Managing difficult-to-treat arthritis"},"content":{"rendered":"

This is the lay version of the EULAR points to consider on the management of people with difficult-to-treat rheumatoid arthritis. The original publication can be downloaded from the EULAR website: www.eular.org. Nagy G, et al. EULAR points to consider for the management of difficult-to-treat arthritis. Ann Rheum Dis doi:10.1136\/annrheumdis-2021-220973<\/a><\/p>\n

Introduction<\/strong>
\nEULAR recommendations give advice to doctors, nurses and patients about the best way to treat and manage diseases. These are the first EULAR-endorsed points on the best way to treat people with difficult-to-treat rheumatoid arthritis. Based on the low level of evidence available for this topic, it was not possible to develop full recommendations, and the work has been presented instead as \u2018points to consider\u2019.<\/p>\n

Doctors, other health professionals, and patients worked together to develop this advice. The patients in the team ensured that the patient point of view was included. The authors looked at the evidence on difficult-to treat rheumatoid arthritis, and the use of different pharmacological and non-pharmacological management options in people with this type of disease.<\/p>\n

What do we already know?<\/strong>
\nRheumatoid arthritis is a condition where the joints become stiff, painful, and damaged due to the immune system attacking the body\u2019s own tissues and causing inflammation. Although there are many treatment options for rheumatoid arthritis, some people do not reach low disease activity or remission and may still have symptoms after several cycles of treatment. These people are referred to as having \u201cdifficult-to-treat\u201d disease. Managing difficult-to-treat disease can be very challenging, and until now there has not been any specific guidance for people with this kind of rheumatoid arthritis.<\/p>\n

These points include information on different types of disease modifying anti-rheumatic drugs (often shortened to DMARDs) that are used to treat rheumatoid arthritis. These drugs aim to change the course of the disease by reducing inflammation, and can prevent flares and disease worsening. They can also help to improve function and stop the progression of joint damage. The three different types used in rheumatoid arthritis are:<\/p>\n

\u2022 Conventional synthetic DMARDs (sometimes shortened to csDMARDs)
\n\u2022 Biologic DMARDs (also called bDMARDs, biologics or biologicals)
\n\u2022 Targeted synthetic DMARDs (shortened to tsDMARDs).<\/p>\n

What do the points say?<\/strong>
\nIn total, there are two overarching principles and 11 points to consider. The principles stress that this guidance is specifically for people who meet the official definition of difficult-to-treat. The points are underpinned by the EULAR recommendations for the general management of rheumatoid arthritis. The second principle states that it should be established whether a person has inflammation or not. This information guides the choice of pharmacological and non-pharmacological interventions.<\/p>\n

The 11 points to consider cover confirming the diagnosis of difficult-to-treat rheumatoid arthritis, 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.<\/p>\n

Each point is based on the best current knowledge and studies of scientific evidence or expert opinion. The more stars a point has the stronger the evidence is. However, points to consider with limited scientific evidence may be important because the experts can have a strong opinion even when the published evidence may be lacking.<\/p>\n

One star (*) means it is a point with limited scientific evidence.
\nTwo stars (**) means it is a point with some scientific evidence.
\nThree stars (***) means it is a point with quite a lot of scientific evidence.
\nFour stars (****) means it is a point supported with a lot of scientific evidence.<\/p>\n

\u2022 If a person is thought to have difficult-to-treat rheumatoid arthritis, the possibility of
\nmisdiagnosis or multiple co-existing diseases should be considered as a first step. *<\/strong>
\nRheumatoid arthritis can be confused with other diseases with similar symptoms. People may also
\nhave more than one disease at the same time. Diseases that can be misdiagnosed as rheumatoid
\narthritis include other types of arthritis, Still\u2019s disease, lupus, inflammatory myopathies, vasculitis, or fibromyalgia. Getting an accurate diagnosis is important to help choose the best treatment.<\/p>\n

\u2022 Where there is doubt on the presence of inflammatory activity based on clinical assessment
\nand composites, health professionals should consider using ultrasound. **<\/strong>
\nIn clinical practice, doctors use physical examinations and composite measures to decide if there is
\ninflammation present in a joint. Composites are a way of using a number of different measures to get
\nan overall score. However, in people with difficult-to-treat disease these can be hard to interpret.
\nWhen traditional techniques are challenging, ultrasound may be the best way to see if there is
\ninflammation present.<\/p>\n

\u2022 Composite indices and clinical evaluation should be interpreted with caution in the presence
\nof comorbidities, as these may overestimate disease activity. *<\/strong>
\nOther conditions such as obesity and fibromyalgia may coexist with rheumatoid arthritis. When this is
\nthe case clinical measures and composites should be interpreted with caution. This is because
\ncomorbidities can directly intensify inflammatory activity. This may affect estimates of disease
\nactivity.<\/p>\n

\u2022 Your treatment adherence will be discussed and optimised within the process of shared
\ndecision-making.*<\/strong>
\nBetween 30% and 80% of people with rheumatoid arthritis do not take their treatment as prescribed.
\nThe rates are thought to be even higher in people with difficult-to-treat disease. This can result in
\nhigher disease activity levels and may contribute to inappropriate treatment choices and poor quality
\nof life. Shared-decision making with your healthcare team can help you to improve your adherence.
\nThis should be discussed as part of your treatment plan.<\/p>\n

\u2022 After failure of a second or subsequent b\/tsDMARD a different target should be considered.**<\/strong>
\nIf you have tried two or more b\/tsDMARD therapies \u2013 and especially if you have tried two different
\nmedicines in the TNFi class (Tumour Necrosis Factor inhibitor) \u2013 a medicine with a different target
\nshould be considered. Biologic and targeted synthetic DMARDs act on many different molecules and
\nprocesses in the body. Switching to a different mechanism might be helpful.<\/p>\n

\u2022 If a third or subsequent b\/tsDMARD is being considered, the maximum dose should be
\nused.**<\/strong>
\nFor people who have not responded to two b\/tsDMARDs already, a third can be tried. This should be
\nstarted at the maximum approved dose.<\/p>\n

\u2022 Comorbidities that impact quality of life should be carefully considered and managed.*<\/strong>
\nPeople with rheumatoid arthritis may have other diseases at the same time. These are called
\ncomorbidities. These can have an impact on quality of life \u2013 either directly, or indirectly by limiting
\ntreatment options for the arthritis. For example, people with herpes zoster infection cannot use JAK
\ninhibitors, and people with a digestive disease called diverticulitis cannot use tocilizumab.
\nComorbidities should be carefully managed and treated to limit their impact on treatment choices for
\npeople with difficult-to-treat rheumatoid arthritis.<\/p>\n

\u2022 In people with hepatitis B or C infection, b\/tsDMARDs can be used;** antiviral treatment
\nshould be considered in close collaboration with a hepatologist.*<\/strong>
\nIf you have hepatitis B or C (often shortened to HBV or HCV), you can still use b\/tsDMARDs for your
\nrheumatoid arthritis. You may need to have treatment for the hepatitis before you can start the
\nrheumatoid arthritis treatment. This will be managed by your healthcare team.<\/p>\n

\u2022 In addition to pharmacological treatment, non-pharmacological interventions should be
\nconsidered to optimise management of functional disability, pain, and fatigue.**<\/strong>
\nA number of factors can contribute to the signs and symptoms of rheumatoid arthritis, and not all of
\nthese can be fixed with medicines. Non-pharmacological interventions include recommendations on
\nexercise, psychological wellbeing, education, and self-management. These should be considered to
\nhelp you managed if you have disability caused by your rheumatic arthritis, or if you experience pain
\nand fatigue (extreme tiredness).<\/p>\n

\u2022 You should be offered education and support to directly inform you about your choices for
\ntreatment goals and management.**<\/strong>
\nSetting treatment goals is important in the management of rheumatoid arthritis. These are usually
\nclinical remission or low disease activity after 3 or 6 months of a particular treatment. However, these goals may not be appropriate for people with difficult-to-treat disease. If you have difficult-to-treat rheumatoid arthritis, your goals should be tailored to your particular circumstances. Being informed about your disease will help you understand your goals. You should be offered education and
\nsupport to help you make informed choices, and to participate in your management.<\/p>\n

\u2022 You should be offered self-management programmes, education or psychological
\ninterventions to optimise your ability to manage your disease confidently.**<\/strong>
\nSelf-efficacy is important in rheumatoid arthritis. This refers to your ability to control or manage
\nvarious aspects of your disease. People with low self-efficacy are more likely to give up on their
\ngoals, and may be more likely to have pain, fatigue, depression, or stress. There are programmes
\nthat can help you to improve your self-efficacy. These may focus on educating you about your
\ndisease so that you are armed with the right knowledge. Or they may give you strategies for coping with pain, or improving relaxation. These are optional, but if you are interested in improving your self-efficacy you should speak to your healthcare team.<\/p>\n

Summary<\/strong>
\nOverall, the points highlight how much more evidence is needed to make recommendations. In the meantime, EULAR hopes these will be a useful roadmap for health professionals involved in the care of people with difficult-to-treat rheumatoid arthritis. They should be used alongside the main recommendations for rheumatoid
\narthritis.<\/p>\n

If you have any questions or concerns, you should speak to a health professional involved in your care.<\/p>\n

Disclaimer:<\/strong> This is a summary of a scientific article written by a medical professional (\u201cthe Original Article\u201d). The Summary is written to assist non medically trained readers to understand general points of the Original Article. It is supplied \u201cas is\u201d without any warranty. You should note that the Original Article (and Summary) may not be fully relevant nor accurate as medical science is constantly changing and errors can occur. It is therefore very important that readers not rely on the content in the Summary and consult their medical professionals for all aspects of their health care and only rely on the Summary if directed to do so by their medical professional. Please view our full Website Terms and Conditions<\/a>.<\/p>\n

Copyright<\/strong> \u00a9 2021 BMJ Publishing Group Ltd & European League Against Rheumatism. Medical professionals may print copies for their and their patients and students non commercial use. Other individuals may print a single copy for their personal, non commercial use. For other uses please contact our Rights and Licensing Team<\/a>.<\/p>\n","protected":false},"excerpt":{"rendered":"

This is the lay version of the EULAR points to consider on the management of people with difficult-to-treat rheumatoid arthritis. The original publication can be downloaded from the EULAR website: www.eular.org. Nagy G, et al. EULAR points to consider for the management of difficult-to-treat arthritis. Ann Rheum Dis doi:10.1136\/annrheumdis-2021-220973 Introduction EULAR recommendations give advice to […]<\/p>\n

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