Response to: 'Correspondence on 'EULAR definition of difficult-to-treat rheumatoid arthritis'' by Novella-Navarro et al .

We read with great interest the correspondence of Novella-Navarro et al on our paper regarding the European League Against Rheumatism (EULAR) definition of difficult-to-treat rheumatoid arthritis (D2T RA).1 2 We appreciate their acknowledgement of the need for uniform terminology and a uniform definition to describe the concept of D2T RA. Previously, this need had also been underlined by rheumatologists participating in an international survey.3 The use of heterogeneous terminology and definitions might hamper research and management of these patients.4–9\n\nNovella-Navarro et al compared their definition of multirefractory RA in their recently conducted retrospective study with the three criteria of the EULAR definition of D2T RA (box 1).2 10 They classified patients with RA as having ‘multirefractory’ disease after failing ≥2 biological and/or targeted synthetic disease-modifying antirheumatic drugs (b/tsDMARDs) with different mechanisms of action or ≥3 b/tsDMARDs with the same target, and as having ‘non-refractory’ disease if achieving low disease activity or remission on the first bDMARD. Noteworthy, 96% of their multirefractory patients met the EULAR definition of D2T RA (box 1),2 which supports the clinical usefulness of our definition.1\n\nBox 1 \n### EULAR definition of difficult-to-treat rheumatoid arthritis1\n\n1. Treatment according to EULAR recommendations and failure of ≥2 b/tsDMARDs (with different mechanisms of action)* after failing csDMARD therapy (unless contraindicated)†\n\n2. Signs suggestive of active/progressive disease, defined as ≥1 of:\n 1. At least moderate disease activity (according to validated composite measures including joint counts, eg, DAS28-ESR\u003e3.2 or CDAI\u003e10)\n 2. Signs (including acute phase reactants and imaging) and/or symptoms suggestive of active disease (joint related or other)\n 3. Inability to taper …