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Background: Despite appropriate treatment, a significant number of patients with rheumatoid arthritis fail to achieve remission. The European League Against Rheumatism (EULAR) recently proposed a definition of patients with difficult-to-treat rheumatoid arthritis (D2T RA), as well as points to consider in its management 1,2. Objectives: The aim of this study was to assess the experience of Tunisian rheumatologists with D2T RA. Methods: Electronic descriptive cross-sectional survey conducted during August and September 2023 among Tunisian rheumatologists of different grades. It consists of a 14-question questionnaire realized via the Google-Forms platform and distributed through social networks. Results: A total of 48 rheumatologists participated (43 women and 5 men). The mean age was 40.48 ± 11.12 26-68 years. Of the participants, 47.9% were in training, 18.8% worked in the private sector and 33.3% in public hospitals, 68.8% of whom were university staff. The average work experience was 12.81 ± 9.67 1-40 years. Fifty-six percent of respondents stated that RA was a frequent pathology in their daily practice. Therapeutic objectives were achieved in most cases for 73.9% of participants, while for the remainder, therapeutic objectives were rarely achieved. According to participating rheumatologists, RA is considered D2T based on disease activity scores (73.9%), clinical and/or biological criteria (60.9%), response to disease-modifying antirheumatic drugs (DMARDs) (56.6%), radiographic progression (56.6%), corticosteroid doses (47.8%), patient perception (43.6%), and physician perception (30.4%). Only 21.7% of participants claimed to be familiar with the EULAR definition of D2T RA. Regarding their perception of the definition of D2T RA: The first item of the definition (treatment according to EULAR recommendation and failure of ≥2 biological (b)DMARDs/targeted synthetic (ts)DMARDs (with different mechanisms of action) after failing conventional synthetic DMARD therapy) was affirmed by 69.6% of participants. The elements of the 2nd item had the following proportions: at least moderate disease activity (47.8%), signs and/or symptoms suggestive of active disease (39.1%), inability to taper glucocorticoid treatment (56.5%), rapid radiographic progression (34.8%), and RA symptoms that are causing a reduction in quality of life (39.1%). The 3rd item (management of signs and/or symptoms perceived as problematic by the rheumatologist and/or patient) was reported by 30.4% of participants. As for the points for consideration proposed by EULAR for the management of D2T RA, the participating rheumatologists adhered to the following points: considering comorbidities that can influence inflammatory activity and/or overestimate disease activity and have an impact on quality of life (73.9%), collaborating with the patient in a "shared medical decision" process (65.2%), proposing b/tsDMARD treatment with a different target in case of failure of a second b/tsDMARD (65, 2%), considering the possibility of misdiagnosis and/or the presence of a coexistent mimicking disease (52.2%), using the maximum treatment dose when using a 3rd b/tsDMARD (34.8%), considering non-pharmacological interventions to optimize disease management (30.4%). Conclusion: D2T RA is a highly emerging concept. A better understanding of this entity would improve the management of RA patients. REFERENCES: 1 Nagy G, Roodenrijs NMT, Welsing PM, Kedves M, Hamar A, van der Goes MC et al. EULAR definition of difficult-to-treat rheumatoid arthritis. Ann Rheum Dis. 2021 Jan;80(1):31-35. doi: 10.1136/annrheumdis-2020-217344. Epub 2020 Oct 1. PMID: 33004335; PMCID: PMC7788062. 2 Nagy G, Roodenrijs NMT, Welsing PMJ, Kedves M, Hamar A, van der Goes MC et al. EULAR points to consider for the management of difficult-to-treat rheumatoid arthritis. Ann Rheum Dis. 2022 Jan;81(1):20-33. doi: 10.1136/annrheumdis-2021-220973. Epub 2021 Aug 18. PMID: 34407926; PMCID: PMC8761998. Acknowledgements: NIL. Disclosure of Interests: None declared.
Tbini et al. (Sat,) studied this question.