de Hair et al reported criteria for the diagnosis of difficult-to-treat rheumatoid arthritis (RA). The authors are from University Medical Center Utrecht.
Criteria for a diagnosis of difficult-to-treat rheumatoid arthritis:
(1) RA disease with persistent signs and symptoms of inflammatory activity (failure to adequately respond)
(2) therapy with conventional- synthetic diseases modifying antirheumatic drugs (DMARDs) and at least 2 biological DMARDs
A presumption is that the therapy was done appropriately in terms of dose and duration of therapy.
The authors report a 3-10% prevalence of difficult-to-treat RA in their practice.
Factors that may interfere with therapy:
(1) smoking
(2) pharmacogenetics with decreased drug effect
(3) antibodies to biological DMARDS
(4) noncompliance
Differential diagnosis:
(1) misdiagnosis of rheumatoid arthritis
(2) adverse drug reactions
(3) comorbidities
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