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Pearls of wisdom on poly-refractory rheumatoid arthritis

By Priscilla Lynch - 19th May 2025

poly-refractory rheumatoid arthritis
iStock.com/Serdar Kutlu

Irish Society for Rheumatology, Spring Meeting, Sligo Park Hotel, 10-11 April 2025

Despite major advances in rheumatoid arthritis (RA) treatment over the past three decades, a significant minority of patients fail to respond to multiple disease-modifying therapies. These patients are often described as having ‘difficult-to-treat’, ‘treatment-resistant’, or ‘refractory’ RA.

Addressing how best to classify and manage this group – particularly when all conventional options have been exhausted – was the focus of a talk by Prof Dennis McGonagle, Professor of Investigative Rheumatology, University of Leeds, at the 2025 Irish Society for Rheumatology Spring Meeting.

His overview of refractory RA focused on two types of patients.

The first type are patients for whom multiple targeted therapies lack efficacy and who have persistent inflammatory pathology, “which we designate as persistent inflammatory refractory RA (PIRRA).”

The second are those with supposed refractory RA who have continued disease activity that is predominantly independent of objective evidence of inflammation, “which we designate as non-inflammatory refractory RA (NIRRA).”

These two types of disease are not mutually exclusive, but identifying those individuals with predominant PIRRA or NIRRA is important, as it informs distinct treatment and management approaches, Prof McGonagle stated.

He discussed various risk factors, such as obesity and smoking, and the findings from his own research on a cohort of 1,600 refractory RA patients.

 When assessing possible refractory RA patients, he stressed the importance of taking a very careful detailed history, and determining if pain and other symptoms are “constant or intermittent”.

Looking to the future, Prof McGonagle cited refining combination therapies and working closer with other disciplines, such as haematology, to address all of the associated factors which are impacting the patient’s disease activity.

Further coverage of the ISR Spring Meeting is available at www.medicalindependent.ie/societies/isr/

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