Rheumatologist Opinion Research Articles

Computer vision detects inflammatory arthritis in standardized smartphone photographs in an Indian patient cohort.

Computer vision extracts meaning from pixelated images and holds promise in automating various clinical tasks. Convolutional neural networks (CNNs), a deep learning network used therein, have shown promise in analyzing X-ray images and joint photographs. We studied the performance of a CNN on standardized smartphone photographs in detecting inflammation in three hand joints and compared it to a rheumatologist's diagnosis. We enrolled 100 consecutive patients with inflammatory arthritis with an onset period of less than 2 years, excluding those with deformities. Each patient was examined by a rheumatologist, and the presence of synovitis in each joint was recorded. Hand photographs were taken in a standardized manner, anonymized, and cropped to include joints of interest. A ResNet-101 backbone modified for two class outputs (inflamed or not) was used for training. We also tested a hue-augmented dataset. We reported accuracy, sensitivity, and specificity for three joints: wrist, index finger proximal interphalangeal (IFPIP), and middle finger proximal interphalangeal (MFPIP), taking the rheumatologist's opinion as the gold standard. The cohort consisted of 100 individuals, of which 22 of them were men, with a mean age of 49.7 (SD 12.9) years. The majority of the cohort (n = 68, 68%) had rheumatoid arthritis. The wrist (125/200, 62.5%), MFPIP (94/200, 47%), and IFPIP (83/200, 41.5%) were the three most commonly inflamed joints. The CNN achieved the highest accuracy, sensitivity, and specificity in detecting synovitis in the MFPIP (83, 77, and 88%, respectively), followed by the IFPIP (74, 74, and 75%, respectively) and the wrist (62, 90, and 21%, respectively). We have demonstrated that computer vision was able to detect inflammation in three joints of the hand with reasonable accuracy on standardized photographs despite a small dataset. Feature engineering was not required, and the CNN worked despite a diversity in clinical diagnosis. Larger datasets are likely to improve accuracy and help explain the basis of classification. These data suggest a potential use of computer vision in screening and follow-up of inflammatory arthritis.

Percepción del profesional sanitario sobre el paciente con síndrome de sensibilidad central-fibromialgia

Background and objectivesFibromyalgia is characterized by musculoskeletal pain and asthenia of chronic course. Fibromyalgia patients are often a challenge for the health care community as a whole. Existing studies are often limited to the opinion of rheumatologists or family physicians. With this study we seek to know what are the actions, perceptions and knowledge of health professionals as a whole when caring for patients with this disease. Materials and methodsDescriptive cross-sectional study, by means of a self-administered and anonymous survey. Distributed mainly in hospital wards and primary care centers. Statistical analysis of the variables collected was performed (P˂.05). ResultsTwo hundred surveys were collected, most of them physicians (63.5%; n=127) or nurses (25.5%; n=51). 71% of physicians reported using the WHO analgesic scale. 53% (n=59) use NSAIDs or paracetamol. Antidepressants are the third drug of choice. Most believe that the referral specialists should be rheumatologists or primary care physicians, a similar percentage, that management should be multidisciplinary. Fifty two percent feel discouraged or annoyed when dealing with these patients. Physicians have more negative connotations and believe that the care that the patient receives is mostly influenced by the diagnosis of fibromyalgia, compared to nurses and other professionals. ConclusionsOur study shows that the lack of knowledge and therapeutic tools generates, to a large extent, frustration and discomfort in health personnel. It is important to develop new approaches to this entity.

Bilateral combined anterior and posterior scleritis – A case of organ-limited idiopathic vasculitis

We present a case of a 69-year-old female with complains of bilateral painful red eyes and blurred vision. The patient was treated elsewhere for allergic conjunctivitis and then came here for a second opinion. The patient was diagnosed as a case of bilateral anterior plus posterior scleritis based on clinical findings, optical coherence tomography (OCT), and ultrasound B-scan reports. Thorough systemic evaluation for the possibility of infection and systemic vasculitis was performed based on a rheumatologist opinion. Topical and systemic steroids along with cyclophosphamide were started after admitting the patient for diabetes monitoring. The patient regained the best corrected vision from 6/12 to 6/6 with complete resolution of OCT findings after 15 days. This case highlights the importance of thorough eye check-up including posterior segment evaluation in all cases of scleritis and a multi-disciplinary approach in order to achieve early remission of the episode.

"Reuma-Check": Performance of a Comprehensive Fast-Track Program for the Diagnosis of Axial Spondyloarthritis in South America.

The aim of this study was to evaluate the performance of a comprehensive diagnosis program called "Reuma-check" for the diagnosis of axial spondyloarthritis (SpA) in patients with low back pain (LBP). This is a cross-sectional study. Patients with LBP aged 18 years or older were preselected, and those with at least 1 SpA feature completed the circuit. They were referred after 2 strategies: education for orthopedists and a campaign on social networks. All patients underwent a clinical evaluation, laboratory testing, and imaging (including human leukocyte antigen B27 evaluation and magnetic resonance imaging). The diagnosis of axial SpA was established by an expert rheumatologist opinion. Time from onset of symptoms to "Reuma-check," time from patient referral to admission of the checkup, and time from "Reuma-check" to diagnosis were evaluated. A total of 175 of 246 patients were included, most of them came from the social media campaign (55%). Seventy-five (43%) of 175 patients were diagnosed as axial SpA. The median time from referral (or self-referral) to access to the program was 1.3 months. The median time from symptoms onset to access to the program was 31.7 months, and the median time from the performance of "Reuma-check" to final diagnosis was 2 weeks. Features associated with a diagnosis of axial SpA were as follows: inflammatory LBP (odds ratio [OR], 6.64; 95% confidence interval [CI], 1.6-28), clinical enthesopathy (OR, 4.56; 95% CI, 1.1-18.4), positive human leukocyte antigen B27 (OR, 23.02; 95% CI, 3.5-58), and positive magnetic resonance imaging (OR, 14.34; 95% CI, 3.5-58). "Reuma-check" allowed a high frequency of axial SpA diagnosis and improved access to rapid diagnosis, shortening the time from referral to diagnosis with a shorter acquisition time for the ancillary studies. Patients with a final diagnosis of axial SpA presented distinctive features.

Poster Presentation

Poster Presentation

NATIONAL REGISTRY OF INTERSTITIAL LUNG DISEASE FROM PAKISTAN

SESSION TITLE: Diffuse Lung Disease Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: October 18-21, 2020 PURPOSE: The aim of this study was to determine the epidemiology and characteristics of interstitial lung disease from Pakistan. METHODS: This web-based registry which is the first multicenter registry of ILD from Pakistan recruited patients from 10 centers of 5 major cities between January 2016 and March 2019.The ILD diagnosis was based on high-resolution computed tomography (HRCT) and histopathology in cases where biopsy was performed. The opinion of rheumatologist was also sought in cases of CTD related ILDs. The purpose of this multidisciplinary discussion (MDD) resource group was to maintain uniformity in the diagnostic criteria. RESULTS: A total of 744 patients were enrolled in the registry. The final ILD diagnoses were as follows: IPF 256 (34.4%), HP 132 (17.7%), iNSIP 125 (16.8%), CTD-ILD 121 (16.3%), sarcoidosis 68 (9.1%) and 42 (5.7%) were other ILDs. The median age was 57.5 years with interquartile range 46–65 years and gender was predominantly female (65.6%). A mean age greater than 60 years and history of smoking was most significant in IPF patients (P<0.001). The female gender was significant in all ILD's except IPF (P<0.001). The most common clinical symptoms were cough in 674 (90.6%) and dyspnea in 519 (69.75%). On physical examination, crepitations were audible in 674 (90.6%) and rhonchi in 83 (11.2%) while clubbing was seen in 247 (33.2%) which were mostly IPF. Gastroesophageal reflux disease (GERD) was present in 195 (26.2%) patients and was statistically significant with iNSIP and IPF (P=0.021). Echocardiography was done in 432 (58.1%) patients, of which 206 (47.7%) showed pulmonary arterial hypertension (PAH); 44.7% had mild PAH, 30.1% had moderate PAH and 25.2% had severe PAH. The overall predicted forced vital capacity (FVC) was 58.2 ±18.7%. FVC % of predicted was presented as box-and-whiskers plot showing the median, interquartile range and outliers (if any) for ILD patients. The median FVC for IPF was 59 (range: 25-99.99), for iNSIP was 54 (range: 25-99.99), for CTD-ILD was 60.5 (range: 26-99.99), for sarcoidosis it was 67 (range: 26-99.99). The HP patients had the lowest FVC % of predicted median that was 45.5 (range: 25-82) where four cases had ≥85 FVC and considered as outliers (Figure 2). An avian exposure was reported in 105 (79.5%) HP patients and out of which 86.8% were females. CONCLUSIONS: IPF is the most prevalent ILD in Pakistan, followed by HP and iNSIP. An ongoing prospective registry with longitudinal follow-up will help us further elaborate the clinical characteristics, treatment and survival outcome of patients with ILD. CLINICAL IMPLICATIONS: An expansion of the ILD registry to other cities and rural areas of the country with longitudinal follow-up of currently enrolled patients and more stringent validation of data by MDD in tertiary care and National Coordinating Centers could further expand the network and refine disease information. DISCLOSURES: no disclosure on file for Mosavir Ansarie; No relevant relationships by Ali Zubairi, source=Web Response

Magnetic resonance imaging assessment in patients with axial spondyloarthritis: development of checklists for use in clinical practice.

The objective of our study was to standardize magnetic resonance imaging (MRI) assessment of spine and sacroiliac joints in patients with axial spondyloarthritis (axSpA) and/or inflammatory spinal pain, by creating checklists and templates based on the opinions of rheumatologists and radiologists. A scientific committee developed a series of questionnaires with multiple items regarding MRI in patients with axial inflammatory pain and/or axSpA. Then an expert panel of rheumatologists and radiologists rated all items in a 9-point Likert scale. Finally, the scientific committee and the expert panel met to create the definitive documents. Several definitive checklists and templates were generated for rheumatologist-requested MRI and for radiologist-requested MRI reports of sacroiliac joint and spinal examinations. A technical requirement protocol was also agreed on. Our results could be useful in increasing understanding between rheumatologists and radiologists regarding MRI in axSpA diagnosis and follow-up.

Séméiologie clinique de la hanche stricto-sensu (coxo-fémorale)

Nowadays, most young physicians over-trust the accuracy of imaging while underrating the interest of clinical examination to diagnose a pain arising from the coxo-femoral joint. In fact, even MRI can lack sensitivity to diagnose chondral defects and/or labrum tears. Moreover, the performances of clinical tests have been much under-evaluated in the past, when any single test was assessed separately and compared to a gold standard. In fact, a thorough clinical history and the combination of a large number of clinical tests dramatically improve the reliability of rheumatologist's opinion about the exact origin of pain in patients suffering from hip conditions (stricto-sensu, i.e. coxo-femoral joint, labrum, minor teres, and overlying capsule). This state of the art article (including 24 pictures and 20 videos) list the most useful or salient signs to seek for, and the best tests to perform, including some only recently described, to diagnose a pain arising from the hip, “stricto-sensu”.

Comment on: Residual disease activity in psoriatic arthritis: discordance between the rheumatologist's opinion and minimal disease activity measurement: reply.

Comment on: Residual disease activity in psoriatic arthritis: discordance between the rheumatologist's opinion and minimal disease activity measurement: reply.

Perception of Originator Biologics and Biosimilars: A Survey Among Belgian Rheumatoid Arthritis Patients and Rheumatologists.

Among patients and rheumatologists, current knowledge and perception of biosimilars in comparison with originator biologics is unknown. The aim of this study was to investigate this knowledge and perception in Belgian rheumatologists and rheumatoid arthritis (RA) patients. Anonymous web surveys were conducted in Belgian RA patients (n=121) and rheumatologists (n=41) during the period January-March 2016. The surveys covered topics on knowledge, similarity, price, preference, interchangeability, extrapolation and switching. Descriptive and statistical analyses of responses were performed. Familiarity with biosimilars was reported by 49% of patients, of whom 77% knew what biosimilars were. RA patients equally questioned the proven efficacy of originators and biosimilars in RA, as well as their side effects and suitability. Furthermore, RA patients questioned the safety of biosimilars more often than that of originators (35 vs. 20%, respectively; p=0.0094). Rheumatologists, more so than patients, expressed concerns that there might be differences between originators and biosimilars in terms of quality, safety, and price (p=0.0292, p<0.0001, p=0.0129, respectively). The opinions of rheumatologists on interchangeability and extrapolation of indications varied. The price of an originator contributed substantially to the medicine preference of rheumatologists (p=0.0002), but not patients. Our study showed that rheumatologists, more so than patients, were convinced that there can be differences between originators and biosimilars. Despite safety being the major concern of patients, patients trusted their physician's decision to start on or switch to a biosimilar. The evolution of the uptake of biosimilars in Belgium might thus depend mainly on the perception of physicians.

Validation of the EULAR definition of arthralgia suspicious for progression to rheumatoid arthritis.

Recently a EULAR-taskforce defined arthralgia suspicious for progression to RA, in order to allow inclusion of homogeneous sets of arthralgia patients in clinical studies. This longitudinal study aimed (i) to validate this definition in arthralgia patients in whom rheumatologists felt that imminent RA was more likely than other arthralgias [clinically suspect arthralgia (CSA)], that is, the target population fulfilling the entry criterion, and (ii) to explore the performance in arthralgia patients who were referred to secondary care prior to rheumatological evaluation, hence ignoring the entry criterion. The definition was assessed in 241 Dutch patients identified with CSA by rheumatologists and 113 patients referred to the Umeå university hospital with recent-onset arthralgia in small joints. The external reference was arthritis development <2 years' follow-up. CSA patients with a positive definition (⩾3/7 parameters present) had an increased risk for developing arthritis compared with definition-negative CSA patients (hazard ratio = 2.1, 95% CI: 0.9, 4.7). The sensitivity was 84% and the positive predictive value 30%. In arthralgia patients in whom the definition was applied before rheumatological evaluation, a positive definition was neither sensitive (10%) nor predictive (positive predictive value 3%). The EULAR definition of arthralgia suspicious for progression to RA is sensitive when used to support the rheumatologist's opinion on imminent RA. This validation study shows that the definition, when used as designed, further homogenizes patients that rheumatologists consider at risk for RA. To arrive at a high specificity, the clinical definition needs to be combined with biomarkers.

Residual disease activity in psoriatic arthritis: discordance between the rheumatologist's opinion and minimal disease activity measurement.

To assess how many PsA patients with an acceptable disease state according to the treating rheumatologist have quiescent disease defined as minimal disease activity (MDA). This cross-sectional study included 250 PsA patients. To assess current clinical practice as closely as possible, acceptable disease state was not determined by predefined activity measures, but instead was defined by asking rheumatologists to refer those patients whom they considered sufficiently treated. Patients were evaluated for current disease activity including clinical assessments and patient reported outcomes (PROs). One-third (88/250) of the patients with acceptable disease state according to the rheumatologist did not fulfil MDA (MDA-). The presence of tender joints and patient pain and global disease activity scores most frequently contributed to not fulfilling MDA (not achieved in 83, 82 and 80%, respectively). However, also objective signs of disease activity were higher in the MDA- than MDA+ patient group: a swollen joint count >1 occurred in 35% vs 7% (P < 0.001), enthesitis >1 in 14% vs 3% (P = 0.002) and Psoriasis Area and Severity Index >1 in 43% vs 26% (P = 0.002). Residual disease was more frequent in females, elder patients and those with a raised BMI, independent of the treatment schedule, and negatively influenced PROs of function and quality of life. One-third of the PsA patients with acceptable disease state according to the treating rheumatologist did not fulfil the MDA criteria and had residual disease activity on both subjective and objective disease activity measurements. As residual disease activity was associated with worse PROs, future strategy trials should evaluate if treatment adjustments are beneficial for this patient group.

Frequency of concomitant fibromyalgia in rheumatic diseases: Monocentric study of 691 patients.

Fibromyalgia (FM) is a confounding factor for diagnosing and assessing rheumatic disease activity. This study sought to assess the extent of this syndrome in rheumatism patients at a French rheumatology department. This monocentric epidemiological study enrolled all patients consulting due to rheumatoid arthritis (RA), spondyloarthritis (SpA), or connective tissue disease (CTD). FM diagnosis was confirmed or excluded according to the rheumatologist opinion and the 1990 American College of Rheumatology (ACR) criteria. We enrolled 691 patients, including 451 women (65.3%), with a mean age of 55.8 years (18-93). Of the enrolled patients, 325 presented with RA, 298 SpA [59 psoriatic arthritis (PsA), 137 ankylosing spondylitis (AS), 64 non-radiographic SpA (nr-SpA), and 38 peripheral SpA], and 71 CTD. The rheumatologist established FM diagnosis in 97 patients (14%), while 55 (8%) fulfilled the 1990 ACR criteria. The frequency of FM was lower in RA patients (4.9% by 1990 ACR criteria; 7.7% by expert opinion) compared to SpA (11.1% by 1990 ACR, p < 0.05; 17.5% by expert opinion, p < 0.003) and CTD (11.3% by 1990 ACR, non-significant; 28.2% by expert opinion, p < 0.001). In the SpA subgroups, FM was more common in the nr-SpA than in PsA or AS (23.9%, 9.6%, and 6.4%, by 1990 ACR, p = 0.001; 37.3%, 13.5%, and 7.2%, by expert opinion, p < 0.001). FM-like symptoms are commonly associated with rheumatic diseases. The frequency of FM is particularly high in non-radiographic axial SpA, thus raising questions about the specificity of the Assessment of SpondyloArthritis International Society (ASAS) classification criteria.

Study of the agreement between clinical opinion of rheumatologists regarding the need for immunosuppression and the result of renal biopsy in adult patients with lupus nephritis

Abstract Introduction In patients with lupus nephritis it is necessary to define the need for immunosuppressive therapy according to histological class observed in renal biopsy. Objective To evaluate the agreement between the opinions of six independent clinical rheumatologists regarding the need for immunosuppression and the result of renal biopsy in patients with lupus nephritis. Materials and methods A cross-sectional study on the agreement between a diagnostic test in adult patients with systemic lupus erythematosus. Each rheumatologist predicted the outcome of the biopsy. In order to evaluate the agreement, a dichotomous qualitative outcome was defined and was considered zero if it was not necessary to add a cytotoxic (classes I, II and VI), and otherwise was (classes III, IV, V or combinations). The percentage agreement and kappa statistics with a confidence interval of 95% was measured. Results Information was collected on 34 patients, with a total of 204 predictions made by 6 rheumatology interns. Rheumatologists were correct in their clinical impression in 180 cases (88.2% concordance rate, overall kappa of 0.62 (95% CI = 0.48–0.76)). Of the 204 scenarios generated, 162 corresponded to proliferative forms of lupus nephritis, for which the rheumatologists anticipated the need for immunosuppression in 153 and failed to treat in 9 cases (5.5%, or about 1 in 18). Conclusions The clinical opinion of rheumatologist is quite successful in defining the need for immunosuppression. In general, expert opinion could eventually be offered as an alternative choice to renal biopsy for the patient.

Estudio de la concordancia entre la opinión clínica de los reumatólogos con respecto a la necesidad de inmunosupresión y el resultado de la biopsia renal en pacientes adultos con nefritis lúpica

IntroductionIn patients with lupus nephritis it is necessary to define the need for immunosuppressive therapy according to histological class observed in renal biopsy. ObjectiveTo evaluate the agreement between the opinions of six independent clinical rheumatologists regarding the need for immunosuppression and the result of renal biopsy in patients with lupus nephritis. Materials and methodsA cross-sectional study on the agreement between a diagnostic test in adult patients with systemic lupus erythematosus. Each rheumatologist predicted the outcome of the biopsy. In order to evaluate the agreement, a dichotomous qualitative outcome was defined and was considered zero if it was not necessary to add a cytotoxic (classes I, II and VI), and otherwise was (classes III, IV, V or combinations). The percentage agreement and kappa statistics with a confidence interval of 95% was measured. ResultsInformation was collected on 34 patients, with a total of 204 predictions made by 6 rheumatology interns. Rheumatologists were correct in their clinical impression in 180 cases (88.2% concordance rate, overall kappa of 0.62 (95% CI=0.48 to 0.76)). Of the 204 scenarios generated, 162 corresponded to proliferative forms of lupus nephritis, for which the rheumatologists anticipated the need for immunosuppression in 153 and failed to treat in 9 cases (5.5%, or about 1 in 18). ConclusionsThe clinical opinion of rheumatologist is quite successful in defining the need for immunosuppression. In general, expert opinion could eventually be offered as an alternative choice to renal biopsy for the patient.

THE USE OF HYALURONIC ACID IN GONARTHROSIS IN REAL CLINICAL PRACTICE

Objectives. To assess the frequency and preferences when assigning intraarticular therapy with hyaluronic acid (HA) in knee оsteoarthritis (ОА) in clinical practice. Material and methods. The analysis of 200 patient records with knee OA treated at the regional center of rheumatology to assess the frequency and spectrum assignment of НА, profile of patients, who were prescribed HA, and its effectiveness. To assess the opinions of rheumatologists on intraarticular therapy with НА we conducted an anonymous questionnaire of 20 rheumatologists of Ekaterinburg. Results. The analysis showed that intraarticular НА therapy was recommended by rheumatologists to 46% of patients with knee ОА, of which the treatment was performed in only 35%. Patients who received treatment were older and more often took NSAIDs and symptomatic slow-acting drugs. Intra-articular НА therapy was effective in 69% of patients. НА with higher molecular weight were more effective, although rheumatologists prefer НА with low molecular weight. Conclusion. In clinical practice, НА is used widely in the treatment of knee ОА, a positive effect from the treatment noted in more than a half of patients.

Clinical and serological analysis of patients with positive anticyclic citrullinated Peptide antibodies referred through a Rheumatology Central Triage System.

Anticitrullinated protein antibodies (ACPA) are a highly specific and sensitive biomarker for the diagnosis of rheumatoid arthritis (RA). Some patients who were found to have a positive ACPA test were referred to our Rheumatology Central Triage (CT; Calgary, Alberta, Canada) for assessment by a rheumatologist. The objectives of our study were to determine the clinical accuracy of ACPA in establishing a diagnosis of RA in a real-time clinical setting. Cases that met 3 criteria were included in the study: (1) referred to the CT over 3 calendar years (n = 20,389), (2) reason for referral was a positive ACPA test (n = 568), and (3) evaluated by a certified rheumatologist (n = 314). An administrative serological database was used to retrieve specific ACPA results. Of patients referred through our CT for evaluation of a positive ACPA test, 57.6% received a diagnosis of RA; the remainder had a variety of other diagnoses, some of which might be considered early RA (9%). The predictive values of ACPA for the diagnosis of RA were increased when rheumatoid factor (RF) results were included in the analysis. When definite and possible RA were combined and the prevalence of moderate/high ACPA was compared to all other individuals, the positive and negative predictive values for moderate/high ACPA for RA were 74.3% and 68.4%, respectively. About 58% of patients with a positive ACPA referred through a triage system for a rheumatologist opinion received a diagnosis of RA at their first visit. RF provides additional useful information to guide the diagnosis and urgency of referral.

FRI0055 Good Adherence of Rheumatologists to A 10 Year Treat-To-Target Protocol for Patients with Recent-Onset Rheumatoid Arthritis (The Best Study)

BackgroundTreat-to-target therapy (T2T) is recommended in the treatment of rheumatoid arthritis (RA), but appears not yet fully implemented in daily practice.ObjectivesTo evaluate adherence to a T2T strategy and to determine...

AB0532 Diagnostic Performance of the American-European 2002 Criteria and the Preliminary 2012 American Criteria for Primary SjÖGren Syndrome

BackgroundThe diversity of classification criteria for Primary Sjögren's Syndrome (pSS) makes it difficult to draw conclusions from clinical studies. The most commonly used are the 2002 American European criteria. Recently,...

Barriers to Optimal Disease Control for Rheumatoid Arthritis Patients With Moderate and High Disease Activity

To evaluate barriers that prevent rheumatoid arthritis (RA) patients from achieving Disease Activity Score in 28 joints using the erythrocyte sedimentation rate (DAS28-ESR) scores within the current recommended levels for low disease activity (LDA) or clinical remission (DAS28-ESR score <3.2). Using an electronic medical record program, clinical data for RA patients treated in Optimising Patient Outcomes in Australian Rheumatology clinics, with a recorded DAS28-ESR score, were collected at one point in time. The data included demographics, medications, disease measures, and the rheumatologist's opinion of the main barriers preventing improvement to the recommended DAS28 score. Of the 4,037 patients with a recorded DAS28-ESR score, 304 patients (7.5%) had high disease activity (HDA) and 1,211 patients (30%) had moderate disease activity (MDA). For 584 HDA or MDA patients, the barriers to disease control (BTCs) were recorded by the rheumatologist when there was no adjustment to disease-modifying antirheumatic drug (DMARD) therapy. The recorded BTCs were irreversible joint damage (19.7%), patient-driven preference (14.7%), noninflammatory musculoskeletal pain (9.2%), insufficient time to assess the effect of recently initiated DMARDs (9.2%), safety concerns (7.5%), comorbidities (6.5%), resistant disease (6.3%), and other less common reasons. These patients received DMARDs (97.4%), including biologic agents (34.1%), methotrexate (74.8%), and oral corticosteroids (41.8%). This study identified clinical situations in which rheumatologists elected to continue RA patients with MDA or HDA on DMARD therapy without adjustment to achieve clinical remission or an LDA target of a DAS28-ESR score <3.2.