A Practical Approach to Difficult-to-Treat Rheumatoid Arthritis

Rheumatoid arthritis (RA) is a common autoimmune disease affecting 1% of the general population. Difficult-to-treat RA (D2T-RA) refers to a distinct subgroup of patients who experience active or progressive disease despite ≥2 biologic/targeted synthetic disease modifying antirheumatic drugs (DMARDs) after failing conventional synthetic options. It is estimated that up to 1 in 5 RA patients fall under this category, which is highly challenging to manage, and severely impacts the patients' quality of life. However, it is prudent for clinicians to be cognisant of potential pitfalls in diagnosing a patient with D2T-RA, by ensuring that alternative explanations for patient's symptoms and poor disease control have been thoroughly evaluated and addressed. In this article, we offer a practical "ABCDE" framework for frontline clinicians managing patients with suspected D2T-RA, which involves assessing adherence to treatment, bioavailability/drug exposure, comorbidities (smoking, periodontal disease), differential diagnoses (other inflammatory and non-inflammatory causes of patient's symptoms), and escalation of treatment.