Therapeutic strategies for difficult-to-treat refractory rheumatoid arthritis
Difficult-to-treat rheumatoidarthritis(D2T-RA)is an important challenge in the clinical management of RA.According to the definition proposed by European League Against Rheumatism,D2T-RA is seen in 10％-20％of RA population.According to the presence or absence of inflammation,D2T-RA can be primarily divided into two categories:persistent inflammatory D2T-RA and non-inflammatory D2T-RA.The former is often considered to be"true"D2T-RA and active treatment adjustment is therefore recommended as core strategy.Switching to other types of biologic/targeted synthetic disease-modifying anti-rheumatic drugs(b/tsDMARDs)is often the first treatment option of which Janus kinase inhibitors have showen outstanding efficacy in both clinical trials and real-world studies.Higher therapeutic doses of some special drugs(such as baricitinib,and tocilizumab)are also proven to improve the efficacy.Considering the clinical risks and benefits,the b/tsDMARDs combination strategy is not recommended at present.In addition,CAR-T cell therapy and belintuozumab are also expected to become important options for this population.For non-inflammatory D2T-RA,D2T-RA status is often the result of prominent pain,work disability,psychological and social complications.Due to the lack of evidence of inflammation,non-pharmacological interventions(e.g.exercise therapy,psychological interventions)are considered to be more important than escalation of DMARDs treatment.
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