Using this definition of difficult-to-treat RA, 5–20% of all patients with RA may fit into this category.2
Contributing Factors
Dr. van Laar discussed work that he and colleagues undertook to better understand the contributing factors and burden of disease seen in patients with difficultto-treat RA. In this prospective study, 52 patients with RA were classified as having difficult-to-treat disease and compared with 100 patients with RA who did not meet this definition.3 The authors identified lower socioeconomic status at the onset of RA as an independent risk factor for the development of difficult-to-treat disease.
Other factors that were independently associated with difficult-to-treat disease include limited drug options as a result of adverse events from therapy, mismatch between doctor and patient in the wish to intensify treatment, fibromyalgia and poorer coping skills. A higher prevalence of alcohol use, anxiety and depression was seen in patients with difficult-to-treat disease, compared with controls.
In evaluating the financial aspects of care, patients with difficult-to-treat RA generated about double the healthcare costs of patients without difficult-to-treat disease. The main driver of costs is not just medications, but also the time that family members, friends and relatives invest in caring for these patients. This leads to lost work productivity and collateral costs to these individuals and to society.
In evaluating the financial aspects of care, patients with difficult-to-treat RA generated about double the healthcare costs of those patients without difficult-to-treat disease.
Workflow
A workflow can be used in approaching patients with difficult-to-treat RA. If a patient with RA is showing persistent signs and symptoms of disease activity despite treatment, Dr. van Laar noted the clinician’s first step should be to see if the patient meets the EULAR definition of difficult-to-treat disease. The rheumatologist should then assess for comorbidities that can mimic the signs and symptoms of active disease or may interfere with arthritis assessment.
The rheumatologist should also evaluate whether arthritis activity is present, and in some cases where such an assessment is equivocal, use of ultrasound may be indicated. It is also important, in a professional and nonjudgmental way, to speak with the patient and see if medication nonadherence is at play. Once all of these issues have been evaluated and addressed, then changes to pharmacologic treatment can be made while simultaneously increasing focus on nonpharmacological treatments, which include patient education, increased physical exercise and self-management strategies that can help with coping with disease.
