{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,5,6]],"date-time":"2026-05-06T14:00:31Z","timestamp":1778076031736,"version":"3.51.4"},"reference-count":37,"publisher":"BMJ","issue":"1","license":[{"start":{"date-parts":[[2026,2,5]],"date-time":"2026-02-05T00:00:00Z","timestamp":1770249600000},"content-version":"unspecified","delay-in-days":35,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100001691","name":"Grants-in-Aid for Scientific Research","doi-asserted-by":"crossref","award":["no. 23K15360"],"award-info":[{"award-number":["no. 23K15360"]}],"id":[{"id":"10.13039\/501100001691","id-type":"DOI","asserted-by":"crossref"}]}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["RMD Open"],"accepted":{"date-parts":[[2026,1,11]]},"published-print":{"date-parts":[[2026,1]]},"abstract":"<jats:sec>\n                    <jats:title>Objectives<\/jats:title>\n                    <jats:p>To assess the effectiveness of switching biological or targeted synthetic disease-modifying antirheumatic drugs (b\/tsDMARDs) in patients with low-inflammatory difficult-to-treat rheumatoid arthritis (D2T RA).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>Using the multicentre FIRST registry, we identified D2T RA between August 2013 and March 2024. Low-inflammatory D2T RA was defined as a swollen 28-joint count \u22641\u2009and C-reactive protein &lt;10\u2009mg\/L. In the low-inflammatory D2T RA group, we compared those who underwent b\/tsDMARD switching (the switch group) with the non-switch group. The primary outcome was the 6-month change in Clinical Disease Activity Index (CDAI).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Among 3519 patients, 457 fulfilled the D2T RA criteria, and 173 were low-inflammatory D2T RA. Compared with inflammatory D2T RA, these patients had a shorter disease duration (127.4 vs 146.4 months), lower methotrexate (9.2 vs 10.5\u2009mg\/week) and glucocorticoid doses (4.3 vs 5.2\u2009mg\/day), and higher rates of fibromyalgia (2.9% vs 1.4%) and psychological disorders (5.2% vs 1.8%). The proportion receiving b\/tsDMARD switching was lower in low-inflammatory than in inflammatory D2T RA (29\/173 (16.8%) vs 217\/284 (76.4%)). In the propensity score-matched analysis, the switch group (n=15) showed greater improvements in CDAI and pain than the non-switch group (n=30) (\u22126.6 vs \u22122.2, \u221215.3 vs \u22123.4, both p&lt;0.05). Even among patients with low-grade sonographic activity (greyscale \u22641, power Doppler=0), b\/tsDMARD switching improved CDAI (16.8 to 9.7).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>A subset of patients with low-inflammatory D2T RA may benefit from b\/tsDMARD switching, indicating that low-inflammatory status alone should not preclude consideration of treatment intensification.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1136\/rmdopen-2025-006513","type":"journal-article","created":{"date-parts":[[2026,2,5]],"date-time":"2026-02-05T14:25:14Z","timestamp":1770301514000},"page":"e006513","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":2,"title":["Real-world effectiveness of b\/tsDMARD switching in low-inflammatory difficult-to-treat rheumatoid arthritis: insights from the FIRST registry"],"prefix":"10.1136","volume":"12","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-6220-1233","authenticated-orcid":false,"given":"Hidenori","family":"Sakai","sequence":"first","affiliation":[{"name":"First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4003-8842","authenticated-orcid":false,"given":"Koshiro","family":"Sonomoto","sequence":"additional","affiliation":[{"name":"Department of Clinical Nursing, School of Health Sciences, University of Occupational and Environmental Health, Kitakyushu, Japan"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2209-8454","authenticated-orcid":false,"given":"Shingo","family":"Nakayamada","sequence":"additional","affiliation":[{"name":"First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0009-0003-0212-172X","authenticated-orcid":false,"given":"Masanobu","family":"Ueno","sequence":"additional","affiliation":[{"name":"First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0383-1091","authenticated-orcid":false,"given":"Atsushi","family":"Nagayasu","sequence":"additional","affiliation":[{"name":"First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0266-2342","authenticated-orcid":false,"given":"Takafumi","family":"Aritomi","sequence":"additional","affiliation":[{"name":"First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3022-1317","authenticated-orcid":false,"given":"Hiroaki","family":"Tanaka","sequence":"additional","affiliation":[{"name":"Department of Medical Informatics and Management, Hospital of the University of Occupational and Environmental Health, Kitakyushu, Japan"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9693-9263","authenticated-orcid":false,"given":"Satoshi","family":"Kubo","sequence":"additional","affiliation":[{"name":"First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Ippei","family":"Miyagawa","sequence":"additional","affiliation":[{"name":"Department of Molecular Targeted Therapeutics, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Yasuyuki","family":"Todoroki","sequence":"additional","affiliation":[{"name":"Department of Molecular Targeted Therapeutics, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6484-2360","authenticated-orcid":false,"given":"Yurie","family":"Satoh-Kanda","sequence":"additional","affiliation":[{"name":"First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4163-9356","authenticated-orcid":false,"given":"Yuya","family":"Fujita","sequence":"additional","affiliation":[{"name":"First Department of Internal Medicine, School of Medicine, 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