Non-adherence in difficult-to-treat rheumatoid arthritis from the perspectives of patients and rheumatologists: a concept mapping study

Characterization of patients with rheumatoid arthritis not using biologic/targeted synthetic disease-modifying drugs despite insufficient disease control: Another difficult-to-treat RA

OBJECTIVES

To understand the prevalence and characteristics of rheumatoid arthritis (RA) patients not using biologic/targeted synthetic disease-modifying drugs (b/tsDMARDs) despite insufficient disease control.

METHODS

The data from 3172 RA patients in the FRANK (Fukuoka RA NetworK) registry, a Japanese registry of RA patients, were analysed. The patients were divided into groups based on the use of b/tsDMARDs and the reasons for not using them. Age, disease duration, drug use, activity of daily living (ADL) and quality of life (QOL) measures, the frequency of workers, and satisfaction with treatment were compared among the groups.

RESULTS

About 10% of RA patients in the FRANK registry are non-users of b/tsDMARDs despite disease activity. The three major reasons for not using were the presence of comorbidity, economic reasons, and the patient's intent except for economic reasons. Patients with comorbidity and/or older age have low ADL/QOL but are mostly satisfied with the treatment. Intriguingly, patients not using b/tsDMARDs due to economic reasons are the youngest and have the highest proportion of workers.

CONCLUSIONS

We revealed the status of RA patients, non-users of b/tsDMARDs despite disease activity, who are not included in the European Alliance of Associations for Rheumatology (EULAR)-defined difficult-to-treat RA. About half of them might benefit from b/tsDMARD by patient education and socioeconomic support.

Impact of orthopaedic surgical intervention on difficult-to-treat rheumatoid arthritis: A propensity score-matched study

OBJECTIVE:

To elucidate the therapeutic effect of orthopaedic surgical intervention (OSI) in difficult-to-treat rheumatoid arthritis (D2T RA) compared with non-D2T RA.

METHODS

A total of 534 recent surgeries were analysed only in patients who had undergone OSI since 2016 and for whom a 12-month postoperative follow-up was available. D2T RA was determined according to the European League against Rheumatism definition, and patients with D2T RA were matched to patients with non-D2T RA using propensity scores calculated by a logistic regression analysis. The Health Assessment Questionnaire-Disability Index (HAQ-DI), Disease Activity Index 28 (DAS28), face scale, and patient's assessment of general health were measured repeatedly at baseline and 6 and 12 months and were compared using a two-way analysis of variance.

RESULTS

The HAQ-DI, DAS28, face scale, and general health showed significant postoperative improvements, and there were significant differences in the HAQ-DI and face scale scores between D2T RA and non-D2T RA. An additional analysis with DAS28 as a covariate showed no significant interaction for either, suggesting that these improvements in clinical assessment were due to OSI rather than improved disease activity.

CONCLUSIONS

In the absence of an effective pharmacological treatment strategy, OSI may be an effective treatment modality for the management of D2T RA.

The concept of difficult-to-treat disease in rheumatology: where next?

New pathogenesis-based therapeutics and evidence-based consensus treatment recommendations, often with predefined treatment goals, have remarkably improved outcomes across many chronic diseases. However, a clinically significant subgroup of patients responds poorly to interventions and show a progressive decline in the disease trajectory, which poses an increasing health-care challenge. Difficult-to-treat approaches exist in several areas of medicine and the need for similar definitions has recently also emerged in rheumatology. The term difficult-to-treat refers not only to patients with pathology-driven, treatment-refractory disease, but also implicates multiple other factors that can contribute to patients being in this state, including having few treatment options, misdiagnosis, and coincident psychosocial factors. Therefore, the difficult-to-treat state requires a comprehensive, holistic, multidisciplinary approach that considers the specific characteristics of each disease and the personalised needs of the patient. In this Personal View, we provide an overview of the different aspects of the concept of difficult-to-treat disease, highlight its advantages, and propose the importance of incorporating this concept more widely in the design of rheumatological treatment strategies.

Prevalence and characteristics of adults with difficult-to-treat rheumatoid arthritis in a large patient registry

OBJECTIVES

An estimated 5-20% of patients with rheumatoid arthritis (RA) fail multiple treatments and are considered 'difficult-to-treat' (D2T), posing a substantial clinical challenge for rheumatologists. A European League Against Rheumatism (EULAR) task force proposed a definition of D2T-RA in 2021. We applied EULAR's D2T definition in a cohort of patients with established RA to assess prevalence, and we compared clinical characteristics of participants with D2T-RA with matched comparisons.

METHODS

Data from the longitudinal Brigham and Women's Hospital Rheumatoid Arthritis Sequential Study (BRASS) registry were used. Participants were classified as D2T if they met EULAR's definition. A comparison group of non-D2T-RA patients were matched 2:1 to every D2T patient, and differences in characteristics were evaluated in descriptive analyses. Prevalence rates of D2T were estimated using Poisson regression.

RESULTS

We estimated the prevalence of D2T-RA to be 14.4 (95% CI: 12.8, 16.3) per 100 persons among 1581 participants with RA, and 22.3 (95% CI: 19.9, 25.0) per 100 persons among 1021 who were biologic/targeted synthetic DMARD experienced. We observed several differences in demographics, comorbidities and RA disease activity between D2T-RA and non-D2T-RA comparisons. Varying EULAR sub-criteria among all participants in BRASS resulted in a range of D2T-RA prevalence rates, from 0.6 to 17.5 per 100 persons.

CONCLUSION

EULAR's proposed definition of D2T-RA identifies patients with RA who have not achieved treatment targets. Future research should explore heterogeneity in these patients and evaluate outcomes to inform the design of future studies aimed at developing more effective RA management protocols.

Obesity and fibromyalgia are associated with Difficult-to-Treat Rheumatoid Arthritis (D2T-RA) independent of age and gender

BACKGROUND

There is still a significant proportion of patients with rheumatoid arthritis (RA) in whom multiple therapeutic lines are ineffective. These cases are defined by the EULAR criteria as Difficult-to-Treat RA (D2T-RA) for which there is limited knowledge of predisposing factors.

OBJECTIVE

To identify the clinical features associated with D2T-RA in real-life practice.

METHODS

We retrospectively collected demographic, clinical, and serological data on 458 patients consecutively seen for RA between January 2019 and January 2023. We compared patients fulfilling the D2T-RA criteria with the remaining RA cohort using univariate comparisons and logistic regression to determine the impact of clinical features, comorbidities on outcome variable, adjusted for confounders.

RESULTS

Seventy-one/458 (16%) patients fulfilled the 2021 EULAR criteria for D2T-RA with no significant differences for age (median 62 years interquartile range -IQR- 58- 65 vs. 62 IQR 60 - 63 in non-D2T), gender prevalence (23% in both groups) and positivity rates for rheumatoid factors (62% vs. 62% in non-D2T) and Anti-Citrullinated Protein Antibodies (ACPA) (69% vs. 61% in non-D2T). Conversely, D2T-RA cases had significant longer disease duration (median 15 years IQR 13-17 vs. 10 years IQR 9-11 in non-D2T; p < 0.0001). D2T-RA also had more erosions at baseline (24% vs. 11% in non-D2T; p < 0.0001) and higher disease activity index (CDAI) at the last follow up visit (15.7 ± 10.5 vs. 7.5 ± 8.8 in non-D2T; p < 0.0001). D2T-RA cases suffered with higher frequency of obesity (33% vs. 19% in non-D2T, p = 0.021) and fibromyalgia (25% vs. 10% in non-D2T, p < 0.0001). The multivariate analysis confirmed the correlations of D2T-RA with disease duration (Odds ratio -OR- 1.06, 95% confidence interval -CI-1.03-1.09; p < 0.0001), baseline erosions (OR 2.73, 95% CI 1.28-5.82; p = 0.009), obesity (OR 2.22, 95% CI 1.10-4.50; p = 0.026) and fibromyalgia (OR 3.91, 95% CI 1.76-8.70; p = 0.001), independent of age and gender.

CONCLUSIONS

High disease activity, baseline erosions and disease duration are significantly associated with the D2T phenotype of RA while we confirm the importance of obesity and fibromyalgia.

Difficult-to-treat rheumatoid arthritis: what have we learned and what do we still need to learn?

Difficult-to-treat RA (D2T RA) is an area of high unmet need. The prevalence reported in the first D2T RA cohort studies ranged from 5.5% to 27.5%. Key to the definition is a conviction by the patient and/or rheumatologist that disease management has become problematic and failure of at least two biological or targeted synthetic DMARDs. D2T RA is a multifactorial disease state which was reflected in data from D2T RA cohort studies: these pointed towards high prevalence of comorbidities and/or lower socioeconomic status in D2T RA subgroups, while others had persistent symptoms without these factors being present. A holistic approach is necessary to identify the root problems underlying D2T RA in individual patients. In this review, biological and non-biological drivers that should be considered to be optimized will be discussed in view of what we have learned from patient data emerging from the first D2T RA cohort studies.

Management strategies in rheumatoid arthritis

Management of rheumatoid arthritis (RA) has evolved from simply the direct translation of drug efficacy results from clinical trials to patient care, to a more complex longitudinal process that considers not only drug efficacy but also the safety gestalt of a treatment and patient profiles and preferences, as well as health-economic factors. With numerous DMARDs available to treat RA, knowledge about trial efficacy becomes less important than data that inform an appropriate clinical strategy for their optimal selection and use. Overly ambitious approaches targeting the 'maximum' level of success could, for example, be prone to failure and create frustration, and lead to a large number of patients then being considered as 'difficult to treat'. Safety profiles might be more informative than efficacy profiles for precision medicine approaches. Contemporary RA management strategies might therefore take a more holistic approach, beyond merely efficacy, to the setting of targets that lead to improved compliance rather than aspirational successes, with consideration of each patient's multimorbidity profile and preferences, as well as the safety profile of each treatment. Ultimately, the goal remains unchanged: maximizing health-related quality of life; however, with a focus on optimal balance rather than superlatives.

Real-world clinical outcomes and rationale for initiating abatacept as a first-line biologic for patients with anticitrullinated protein antibody- and rheumatoid factor-positive rheumatoid arthritis

Aim: In rheumatoid arthritis (RA), seropositivity for both anticitrullinated protein antibody (ACPA) and rheumatoid factor (RF) is associated with disease severity and therapeutic response. Biologic (b) disease-modifying antirheumatic drugs (DMARDs) such as abatacept are recommended after inadequate response or contraindication to conventional synthetic DMARDs. This retrospective cohort study aimed to describe changes in Clinical Disease Activity Index (CDAI) measures over 12 months among patients with ACPA+ and RF+ RA with an inadequate response to methotrexate treated with abatacept as a first-line bDMARD. Patients & methods: Patient data were abstracted from medical records by treating rheumatologists. Analyses included McNemar tests for paired proportions or paired t-tests to assess longitudinal changes in CDAI scores, and Kaplan-Meier methods for time-to-event outcomes. Serious AEs and rationale for initiating treatment were recorded. Results: Overall, 296 patients were included. Mean CDAI scores improved (decreased) by 34.0, 61.0 and 74.0% (all p < 0.001) from baseline to 3-6 months, 6-12 months and ≥12 months after abatacept initiation, respectively. Of 279 patients not in CDAI low disease activity (LDA) or remission at baseline, 24.7% of patients achieved it within 6 months, 56.3% within 12 months and 71.0% at any point during follow-up after abatacept initiation. Median time to CDAI LDA/remission was 10.2 months. Serious AEs were reported in 2.4% of patients. Common reasons reported by rheumatologists for initiating abatacept were effectiveness/efficacy (52.7%), safety (31.4%) and patient preference (25.3%). Conclusion: In this analysis of patients with ACPA+ and RF+ RA treated with abatacept as a first-line bDMARD in a clinical practice setting, clinical outcomes and remission rates were improved at all time points, providing real-world evidence to further support the use of abatacept in this patient population.

Characteristics of difficult-to-treat axial spondyloarthritis: Results of a real-world multicentric study

OBJECTIVE

The EULAR task force recently published the difficult-to-treat RA (D2T RA) definition, however, a definition of D2T axSpA is still lacking and limitations in this definition exist. The objectives were to study the characteristics of D2T axSpA patients using the EULAR definition and to study a subgroup of patients with a predefined more stringent definition including a temporal criterion.

METHODS

A multicentric retrospective study was performed. D2T axSpA was defined as failure of≥2 b/tsDMARDs with different mechanism of action. Very D2T axSpA was defined as failure of≥2 b/tsDMARDs in less than 2 years of follow-up. D2T and Very D2T axSpA patients were compared to non-D2T (nD2T) axSpA patients.

RESULTS

Three hundred and eleven axSpA patients were included: 88 D2T axSpA (28.3%) and 223 non-D2T (nD2T) axSpA (71.7%). Peripheral involvement was more prevalent in the D2T group (34.9 vs. 21.4%; P=0.015). BASDAI level at baseline was higher in the D2T group (63.7±16.5 vs. 58.8±14.7; P=0.015). Fibromyalgia was found to be more frequent in the D2T group vs nD2T group (P<0.001). Twelve patients (3.8%) were categorized as very D2T axSpA. Compared to nD2T, Very D2T patients had a higher CRP level at baseline (42.0±31.3 vs. 17.8±23.1; P=0.010). IBD prevalence at baseline was higher in the very D2T group (41.7 vs. 3.1%; P<0.001). None of the very D2T patients presented a fibromyalgia.

CONCLUSION

D2T axSpA was associated with higher disease activity, peripheral involvement, extra-musculoskeletal manifestations and fibromyalgia. Very D2T patients represented a minim proportion of patients after applying a more stringent definition including a temporal criterion of 2 years and might be independent from fibromyalgia.

Exploring the influence of baseline rheumatoid factor levels on TNF inhibitor retention rate in patients with rheumatoid arthritis: a multicentre and retrospective study

OBJECTIVE

To assess whether the retention rate of certolizumab pegol (CZP) was longer than that of other tumour necrosis factor inhibitors (TNFi) based on baseline rheumatoid factor (RF) levels.

METHODS

Longitudinal, retrospective and multicentre study including patients with RA who were treated with any TNFi (monoclonal antibodies (mAB), etanercept (ETA) or CZP). Log-rank test and Cox regressions were conducted to evaluate the retention rate in the three groups according to the level of RF, with the third quartile of the baseline levels used as cut-off: <200 (

RESULTS

A total of 638 individuals and 752 treatments (132 CZP, 439 mAB and 181 ETA) were included. In non-naïve patients with ≥200 IU/mL of RF, those treated with CZP showed a significantly longer retention rate in comparison with mAB and ETA. After matching using the propensity score, patients with ≥200 IU/mL RF levels exhibited longer retention rates with CZP than with mAB (HR 2.3 (95% CI 1.2 to 4.3), or ETA (HR 2.8 (95% CI 1.5 to 5.2). No differences were found between groups in patients with <200 UI/mL.

CONCLUSIONS

CZP showed a longer retention rate than mAB and ETA in patients with very high RF levels (≥200 IU/mL), while these differences were absent in patients with <200 IU/mL levels. The results suggest the potential effect of RF on binding the fragment crystallisable portion of certain TNFi.

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Key Words

• Arthritis, Rheumatoid
• Biological Therapy
• Rheumatoid Factor

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MESH Headings

• Humans
• Retrospective Studies
• Tumor Necrosis Factor Inhibitors/therapeutic use
• Rheumatoid Factor
• Treatment Outcome
• Arthritis, Rheumatoid/drug therapy
• Certolizumab Pegol/therapeutic use
• Etanercept/therapeutic use
• Antibodies, Monoclonal/therapeutic use

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Affiliation(s)

Clementina López-Medina Rheumatology, Reina Sofia University Hospital, Cordoba, Spain GC05, Maimonides Biomedical Research Institute of Cordoba, Cordoba, Spain Medical and Surgical Sciences, University of Cordoba, Cordoba, Spain
Jerusalem Calvo-Gutiérrez Rheumatology, Reina Sofia University Hospital, Cordoba, Spain GC05, Maimonides Biomedical Research Institute of Cordoba, Cordoba, Spain Medical and Surgical Sciences, University of Cordoba, Cordoba, Spain
M Carmen Ábalos-Aguilera GC05, Maimonides Biomedical Research Institute of Cordoba, Cordoba, Spain Medical and Surgical Sciences, University of Cordoba, Cordoba, Spain
Francisco Cepas Medical and Surgical Sciences, University of Cordoba, Cordoba, Spain
Chamaida Plasencia-Rodríguez Rheumatology, La Paz University Hospital, Madrid, Spain IdiPAZ, Madrid, Spain
Ana Martínez-Feito Rheumatology, La Paz University Hospital, Madrid, Spain IdiPAZ, Madrid, Spain
Alejandro Balsa Rheumatology, La Paz University Hospital, Madrid, Spain IdiPAZ, Madrid, Spain
Regina Faré-García Rheumatology, Son Llatzer University Hospital, Palma de Mallorca, Spain
Antoni Juan-Mas Rheumatology, Son Llatzer University Hospital, Palma de Mallorca, Spain
Virginia Ruiz-Esquide Rheumatology, Clinic Hospital, Barcelona, Spain
Luis Sainz Rheumatology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
César Díaz-Torné Rheumatology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
Francisco Javier Godoy-Navarrete Rheumatology, University Hospital of Jaen, Jaén, Spain
Isabel Añón-Oñate Rheumatology, University Hospital of Jaen, Jaén, Spain
Natalia Mena-Vázquez Rheumatology, Hospital Regional Universitario de Málaga, Málaga, Spain Instituto de Investigación Biomédica de Málaga (IBIMA), Málaga, Spain
Sara Manrique-Arija Rheumatology, Hospital Regional Universitario de Málaga, Málaga, Spain Instituto de Investigación Biomédica de Málaga (IBIMA), Málaga, Spain Medicina, Univeristy of Málaga, Málaga, Spain
Marina Soledad Moreno-García Rheumatology, Miguel Servet University Hospital, Zaragoza, Spain
Rafaela Ortega-Castro Rheumatology, Reina Sofia University Hospital, Cordoba, Spain GC05, Maimonides Biomedical Research Institute of Cordoba, Cordoba, Spain Medical and Surgical Sciences, University of Cordoba, Cordoba, Spain
Alejandro Escudero-Contreras Rheumatology, Reina Sofia University Hospital, Cordoba, Spain GC05, Maimonides Biomedical Research Institute of Cordoba, Cordoba, Spain Medical and Surgical Sciences, University of Cordoba, Cordoba, Spain

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Impact of multimorbidity on the first ts/bDMARD effectiveness and retention rate after two years of follow-up in patients with rheumatoid arthritis from the BIOBADASER registry

BACKGROUND

Patients with Rheumatoid Arthritis (RA) have a higher prevalence of comorbidities compared to the general population. However, the implications of multimorbidity on therapeutic response and treatment retention remain unexplored.

OBJECTIVES

(a) To evaluate the impact of multimorbidity on the effectiveness of the first targeted synthetic or biologic disease-modifying antirheumatic drug (ts/bDMARD), in patients with RA after 2-year follow-up; (b) to investigate the influence of multimorbidity on treatment retention rate.

METHODS

Patients with RA from the BIOBADASER registry exposed to a first ts/bDMARDs were included. Patients were categorized based on multimorbidity status at baseline, defined as a Charlson Comorbidity index (CCI) score ≥ 3. A linear regression model, adjusted for sex and age, was employed to compare the absolute DAS28 score over time after ts/bDMARD initiation between the two groups. The Log-Rank test and Kaplan-Meier curve were used to compare the retention rates of the first ts/bDMARD between the groups.

RESULTS

A total of 1128 patients initiating ts/bDMARD were included, with 107 (9.3%) exhibiting multimorbidity. The linear regression model showed significantly higher DAS28 (beta coefficient 0.33, 95%CI:0.07-0.58) over a two-year period in patients with multimorbidity, even after adjusting for age and sex. Finally, no differences in the ts/bDMARD retention rate were found between groups (median 6.94-6.96 years in CCI < 3 vs. 5.68-5.62 in CCI ≥ 3; p = 0.610).

CONCLUSIONS

Multimorbidity in patients with RA was associated with greater DAS28 scores within the first two years after ts/bDMARD initiation, in comparison with patients without multimorbidity. A slightly shorter retention rate was found in patients with multimorbidity, although the difference was non-significant.

A Review of Difficult-to-Treat Rheumatoid Arthritis: Definition, Clinical Presentation, and Management

PURPOSE OF REVIEW

A subset of patients with rheumatoid arthritis (RA) who fail multiple biologic therapies are deemed to have "difficult-to-treat" (D2T) RA. In 2021, a European Alliance of Associations for Rheumatology (EULAR) task force proposed a clinical definition of D2T RA. Here we review RA phenotypes and clinical assessment of RA, propose a different definition of D2T RA, discuss possible D2T RA risk factors, and summarize existing literature on the management of D2T RA.

RECENT FINDINGS

High disease activity at the time of diagnosis or prior to treatment with a biologic is associated with the development of D2T RA. Prolonged time from diagnosis to beginning treatment has been consistently associated with the development of D2T RA. Other clinical factors such as burden of disease, extraarticular disease, obesity, smoking, pain, fatigue, and psychological conditions have inconsistent associations with D2T RA according to current literature. D2T RA is a relatively new concept that represents an area of great need for research regarding the characterization of those with the disease as well as how best to treat the disease. With this gained knowledge, rheumatologists will be able to better identify patients at the time of diagnosis that are likely to develop D2T RA to help guide management.

Characteristics Of Difficult-To-Treat Psoriatic Arthritis: A Comparative Analysis

OBJECTIVE

The EULAR task force recently published the difficult-to-treat rheumatoid arthritis (D2T RA) criteria, however, a definition of D2T patients in psoriatic arthritis (PsA) is still lacking. To date, we have little data concerning D2T PsA, especially in real-world. One of the limitations of the D2T RA EULAR definition is the absence of a temporal criterion. The primary endpoint of this work was to study the characteristics of D2T PsA patients using the EULAR definition. The second objective was to study a sub-group of patients with a predefined more stringent definition including a temporal criterion.

METHODS

A retrospective study was performed in a tertiary center. D2T PsA was defined as failure of ≥ 2 b/tsDMARDs with different mechanism of action. Very D2T PsA was defined as failure of ≥ 2 b/tsDMARDs in less than 2 years of follow-up. D2T and Very D2T PsA patients were compared to nD2T PsA patients using statistical tests.

RESULTS

150 PsA patients were included (from 2004 to 2015): 49 D2T PsA and 101 nD2T PsA. D2T PsA was associated with a higher prevalence of axial involvement (p=0.030), axial and/or peripheral structural damage (p=0.007) at baseline and more bDMARDs discontinuation due to poor dermatological control (p=0.005). There was no significant difference regarding comorbidities such as obesity, smoking status, fibromyalgia or depression. In multivariate analysis, peripheral structural damage at baseline was found to be a predictive factor for D2T PsA with an OR of 2.57 (1.16 to 5.69; p=0.020). 17 PsA (11.3%) patients were categorized as Very D2T PsA. When compared to nD2T group, proportion of obesity was higher (p=0.015) and axial involvement was more prevalent in the Very D2T group (p=0.020).

CONCLUSION

D2T PsA patients had a higher prevalence of axial involvement, peripheral structural damage and therapeutic discontinuation due to poor dermatological control whereas Very D2T PsA patients were more likely obese with axial involvement. Very D2T PsA represent a minim proportion among patients when applying a more stringent definition. Pending the PsA D2T definition by the European and American societies, this study highlights some characteristics that may help practitioners better identify D2T patients.

Healthcare professionals’ perceptions on barriers and facilitators to DMARD use in rheumatoid arthritis

Background

Disease-modifying anti-rheumatic drugs (DMARDs) are the cornerstone of rheumatoid arthritis (RA) treatment. However, the full benefits of DMARDs are often not realized because many patients are sub-optimally adherent to their medication. In order to optimize adherence, it is essential that healthcare professionals (HCPs) understand patients’ barriers and facilitators for medication use. Insight in these barriers and facilitators may foster the dialogue about adequate medication use between HCPs and patients. What HCPs perceive as barriers and facilitators has, so far, scarcely been investigated. This study aimed to identify the perceptions of HCPs on patients’ barriers and facilitators that might influence their adherence.

Methods

This qualitative study was performed using semi structured in-depth interviews with HCPs. An interview guide was used, based on an adjusted version of the Theoretical Domains Framework (TDF). Thematic analysis was conducted to identify factors that influence barriers and facilitators to DMARD use according to HCPs.

Results

Fifteen HCPs (5 rheumatologists, 5 nurses and 5 pharmacists) were interviewed. They mentioned a variety of factors that, according to their perceptions, influence DMARD adherence in patients with RA. Besides therapy-related factors, such as (onset of) medication effectiveness and side-effects, most variation was found within patient-related factors and reflected patients’ beliefs, ways of coping, and (self-management) skills toward medication and their condition. In addition, factors related to the condition (e.g., level of disease activity), healthcare team and system (e.g., trust in HCP), and social and economic context (e.g. support, work shifts) were reported.

Conclusions

This study provided insights in HCPs’ perceptions of the barriers and facilitators to DMARD use patients with RA. Most factors that were mentioned were patient-related and potentially modifiable. When physicians understand patients’ perceptions on medication use, adherence to DMARDs can probably be optimized in patients with RA leading to more effectiveness of treatment outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07459-0.