For many people with rheumatoid arthritis (RA) — an autoimmune disorder that occurs when the immune system mistakenly attacks healthy cells — disease-modifying antirheumatic drugs (DMARDs) are the gold standard of treatment.
DMARDs, which include biologic drugs and targeted synthetic drugs, help slow the progression of the condition and preserve your joints by suppressing your immune system, according to the Arthritis Foundation. DMARDs are commonly used in people who have moderate to severe RA, whose pain and fatigue often interferes with their daily activities.
While DMARDs can be very helpful, not everyone with RA will respond to them, according to Ashima Makol, MBBS, a rheumatologist at the Mayo Clinic in Rochester, Minnesota.
In fact, a “significant proportion” of people with moderate to severe RA have, Dr. Makol says, what’s now being called “difficult-to-treat” or “drug-resistant RA.”
Here’s how to know if you’re one of them and, if you are, what to do about it.
Diagnosing Difficult-to-Treat RA
A study published in the July 2021 issue of the journal Arthritis Research & Therapy found that difficult-to-treat RA affects up to 20 percent of people with the condition. Still, it isn’t always easy for doctors to know who will have difficult-to-treat RA, according to Lynn M. Ludmer, MD, a rheumatologist at Mercy Medical Center in Baltimore.
“Most patients respond to varying degrees to DMARDs — either a biologic or target synthetic DMARDs,” Dr. Ludmer notes. “Unfortunately, as of [now], there is no way to predict in advance which patient will respond to which drug.”
Once a drug is selected, there is usually a three- to six-month trial period where a person needs to take it to see if it will work or not, she says.
“The process of waiting for our drugs to become effective is often quite frustrating for both patients and rheumatologists,” Ludmer explains. “However, it’s important to give each drug long enough to work before declaring the treatment a ‘failure.’”
In 2020, the European Alliance of Associations for Rheumatology (EULAR) came out with an official definition for difficult-to-treat RA. According to the guidelines, which were published in the October 2020 edition of the journal Annals of Rheumatic Diseases, to have difficult-to-treat RA you must:
- Be treated according to current EULAR guidelines and still have symptoms that don’t respond to at least two biological DMARDs or at least two targeted synthetic DMARDs (with different mechanisms of action) after failing conventional synthetic DMARD therapy.
- Have signs of at least moderate disease activity; signs and/or symptoms suggestive of active disease or inability to taper steroid treatment; signs of disease progression on radiography scans; or RA symptoms that are causing a reduction in quality of life.
- Have signs and/or symptoms that are perceived as problematic by you or your rheumatologist.
People with difficult-to-treat RA also often require continued steroid injections and have continued joint pain and swelling, according to Ludmer.
There are some factors that can make it more likely that you’ll have difficult-to-treat RA. For example, if you’ve had a delay in diagnosis or an incorrect diagnosis before, or if you’ve had a delay in starting RA treatment, you may have symptoms that fail to respond to DMARD treatment, Makol says.
Other health conditions can also impact the effectiveness of your RA treatment, she adds.
“Socioeconomic factors and insurance coverage can limit access to certain disease-modifying therapies,” Makol says. “There also can be numerous pain or fatigue generators beyond RA itself, such as an overlapping non-inflammatory condition, hormonal imbalance, depression, poor sleep, and weight gain impairing adequate physical activity, which may complicate the equation further and impact overall functional quality of life and how a person feels.”
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March 01, 2022 at 11:07PM
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Do You Have “Difficult-to-Treat” RA? - Everyday Health
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