Management of therapy-resistant rheumatoid arthritis

During the last two decades, newly introduced therapeutic strategies have resulted in satisfactory modification of the disease course in the majority of the patients with rheumatoid arthritis (RA). Nevertheless, a definite number of RA patients remain therapy-resistant, and for this group more aggressive treatment may be required for preventing permanent disability and progressive joint damage necessitating surgical procedures. Therefore, management of therapy-resistant RA is one of the major challenges in modern rheumatology. RA patients who have not responded to conventional disease-modifying antirheumatic drug (DMARD) therapy are defined as refractory RA patients. However, a uniform description or definition for 'refractory' RA does not appear to be available. In this article we will deal with, and discuss, the term 'refractory RA' based on a MEDLINE database search using this term, currently available therapeutic options, data on therapy-resistant RA patients from an inception cohort of RA patients attending the Nijmegen University Hospital, management of extra-articular manifestations and future management strategies.