Pos1083 difficult to treat inflammatory arthritis: making the definition more precise and time framed

Background Management of difficult to treat (D2T) inflammatory arthritis requires meticulous evaluation for the presence or absence of inflammation to support pharmacological and non-pharmacological management strategies. The challenge arises from the finding that D2T has been linked to a variety of characteristics. The EULAR Task Force has recently defined D2T rheumatoid arthritis as patients having persistency of symptoms and/or signs despite failure of at least two biological or targeted synthetic disease modifying anti-rheumatic drugs with different mechanisms of action. However, the proposed EULAR Task Force definition of D2T was based on just one assessment at one moment of time, during which flare up of the disease may not be reflective of the actual disease activity status. Objectives To address the unmet needs and derive a comprehensive, yet precise, approach to define the inflammatory arthritis patients who are “Difficult-to-Treat”. Methods Five key clinical questions including 20 domains were identified by core scientific committee. Literature Review team performed a systematic review to summarize evidence advocating the D2T definition, assessment and management, as well as benefits and harms of available pharmacologic and non-pharmacologic therapies. Subsequently, recommendations were formulated. The level of evidence was determined for each section using the Oxford Centre for Evidence-based Medicine (CEBM) system. A 3-round Delphi process was conducted. All rounds were conducted online. Consensus, consequently, to become a recommendation, would be achieved if at least 80% of participants reached agreement (score 7-9). A consensus was achieved on the direction and the strength of the recommendations. Results The work proposed an inclusive definition of D2T in inflammatory arthritis based on 4 pillars: “persistent inflammation that continues to cause significant burden despite standard treatment as perceived by the treating rheumatologist and/or the patient”. Two extra factors have been suggested to be added to the EULAR definition. These are “disease burden” and “time-frame” for the assessment of the disease activity status. “Continuous disease burden” has been defined as having difficulties in: Achieving treatment target, controlling disease progression, sustained elevation of the acute phase response over 3 months period attributed to the inflammatory joint disease, lack of functional restoration and poor quality of life despite good symptomatic control, and treatment compliance due to: unacceptable tolerability or non-adherence or rejection of the treatment option. Time frame has been identified as: persistent joint inflammation (active/progressive disease”) has been documented according to validated composite measures including joint counts in 2-readings, 3-months apart. Level of agreement was high and in the range of 8.17-8.83). Conclusion this study revealed a consensus that time factor is vital to consider inflammatory arthritis as persistent, hence meet the difficult to treat definition. Adding the “continuous disease burden has added another dimension to the management of D2T, advocating a more holistic approach toward the patient rather than observing a patient through the prism of the index disease. REFERENCES: NIL. Acknowledgements: NIL. Disclosure of Interests None Declared.