Abstract Background To assess the drug survival and change of disease activity using a second Janus kinase inhibitor (JAKi) after failure to a JAKi and subsequent biologic disease-modifying anti-rheumatic drugs (bDMARDs) in patients with difficult-to-treat rheumatoid arthritis (RA). Methods This retrospective cohort study included 32 patients with difficult-to-treat RA who failed to a JAKi and subsequently to one or more bDMARDs and then switched to a second JAKi. To assess drug survival, electronic medical records of each patient were reviewed. Data on whether the second JAKi was discontinued, and the reasons for discontinuation were collected. The change of disease activity was assessed by analyzing changes in tender joint count (TJC), swollen joint count (SJC), patient’s global assessment of disease activity on a visual-analogue scale (VAS), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), Disease Activity Score for 28 joints with ESR (DAS28-ESR), and DAS28-CRP from baseline to that at six months from initiation of the second JAKi. Results Overall, discontinuation of the second JAKi occurred in 20 (62.5%) patients. Primary failure, secondary failure, adverse events, and insurance coverage issues were the reasons for discontinuation in 9 (45.0%), 5 (25.0%), 2 (10.0%), and 4 (20.0%) patients, respectively. The estimated 2-year drug survival rate was 39.3%. In terms of change of disease activity, the second JAKi significantly improved TJC (p < 0.001), SJC (p < 0.001), VAS (p < 0.001), CRP (p = 0.026), DAS28-ESR (p < 0.001), and DAS28-CRP (p < 0.001) at 6-month compared with that at the baseline. Conclusions Second JAKi could be a therapeutic option in patients with difficult-to-treat RA who have failed to a JAKi and subsequent bDMARDs. (JAKi diseasemodifying modifying antirheumatic anti rheumatic (bDMARDs difficulttotreat difficult treat RA. . (RA) 3 reviewed discontinued collected TJC, , (TJC) SJC, (SJC) s visualanalogue visual analogue VAS, (VAS) ESR, (ESR) Creactive C reactive CRP, (CRP) DAS28ESR, DAS28ESR DASESR DAS28 DAS (DAS28-ESR) DAS28CRP DASCRP Overall 62.5% 625 62 (62.5% events 45.0%, 450 45.0% 45 0 (45.0%) 25.0%, 250 25.0% 25 (25.0%) 10.0%, 100 10.0% 10 (10.0%) 20.0% 200 (20.0% respectively 2year year 393 39 39.3% p 0.001, 0001 0.001 001 0.026, 0026 0.026 026 0.026) 6month month 6 (RA (TJC (SJC (VAS (ESR (CRP DAS2 (DAS28-ESR 62.5 (62.5 45.0 (45.0% 25.0 (25.0% 10.0 1 (10.0% 20.0 (20.0 39.3 000 0.00 00 002 0.02 02 62. (62. 45. (45.0 25. (25.0 10. (10.0 20. (20. 39. 0.0 (62 (45. (25. (10. (20 0. (6 (45 (25 (10 (2 ( (4 (1