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Background: Biologic therapy has revolutionised treatment pathways and improved outcomes for patients with RA. However, for some patients on biologics, disease control remains elusive with so-called refractory disease. The aim was to quantify the frequency of biologic refractory disease and identify factors associated with refractory disease.

Methods: Patients with RA starting first-line TNFi in the BSRBR-RA were included if they had a full 10 years of study follow-up (N ¼ 5755). Patients were classified as refractory if they had used three classes of biologic, and were compared with persistent patients who remained on first TNFi for 10 years. Stop reasons were investigated. HAQ was assessed at three years and DAS28 at 10 years. Associations with age, gender, disease duration, baseline DAS28 and components, comorbidities, HAQ and refractory disease were analysed in a multivariable logistic analysis. Multiple …