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. “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.”
Take all medication as prescribed and at the right dosage. It may seem obvious, but this is the most important thing you can do to treat your RA.If you smoke, quit. Smoking can reduce the effectiveness of RA treatments, according to Makol.Follow a healthy lifestyle. “A healthy, well-balanced diet and good sleep can go a long way, ” says Makol.
How Do I Know if I Have Difficult-to-Treat RA?
If you’re taking your medication as prescribed and you’ve been on it for more than six months, you probably have an idea of how well your current treatment is working, Makol says. “If you have joint pain or swelling, prolonged morning stiffness, or feel poorly despite consistently taking your treatments as advised, you must bring this up during visits” with your rheumatologist, she says. Keeping all your appointments with your rheumatologist will help your doctor monitor your RA and allow you to bring up your concerns. “It’s critical for you to have regular follow-up with your rheumatologist where your disease activity is assessed after a thorough joint exam,” Makol adds. Also, if you have to use steroids frequently due to RA flares and pain despite taking your RA treatment as prescribed, this is a sign you probably need to be on a different treatment, she explains. If you’re frustrated by your current treatment or feel like you may be experiencing difficult-to-treat RA, the first step to take is to talk to your doctor. “The best way for a patient to decide if they have difficult-to-treat RA is to ask their rheumatologist,” Ludmer says. “Establishing an open dialogue with your provider is very important to treatment success.”
