RA Treatment Recommendations From European League Against Rheumatism
Dr. Landewé summarized the following 15 items at the core of the new EULAR rheumatoid arthritis treatment recommendations:
Therapy with synthetic disease-modifying antirheumatic drugs (DMARDs) should start as soon as RA is diagnosed.
Treatment should aim at achieving remission or low disease activity as soon as possible in every patient. As long as these goals are not met, adjustment of treatment should be done with frequent and strict monitoring every 1-3 months.
Methotrexate should be part of the first treatment strategy in patients with active RA, either as monotherapy or in combination therapy.
If patients have contraindications to or are intolerant of methotrexate, then sulfasalazine, leflunomide, and injectable gold should be part of the first treatment strategy.
In DMARD-naive patients, monotherapy with a synthetic DMARD is an alternative to combination therapy with two or more synthetic DMARDs.
Glucocorticoids can be useful, short-term initial therapy in combination with synthetic DMARDs. (“Glucocorticoids are very effective” but present toxicity concerns, Dr. Landewé said.)
If the treatment target isn't achieved with the first DMARD strategy, adding a biologic DMARD should be considered in patients with a poor-prognosis factor. Patients without a poor-prognosis factor are candidates for switching to another synthetic DMARD. Poor-prognosis factors are positivity for rheumatoid factor and anti-cyclic citrullinated peptide antibody, or early erosive disease, rapidly progressing disease, or high disease activity.
Patients who respond inadequately to methotrexate alone or in combination with other synthetic DMARDs should start treatment with a biologic DMARD. Current practice starts with a tumor necrosis factor (TNF) inhibitor, used with methotrexate.
Patients who fail on an initial TNF inhibitor should receive a different TNF inhibitor or receive abatacept, rituximab, or tocilizumab.
Azathioprine, cyclosporin A, and cyclophosphamide, which are considered to be “second-line” DMARDs, can be used as monotherapy or in combination with one of the agents above in patients with severe and refractory RA or contraindications to either biologic DMARDs or the previously mentioned synthetic DMARDs.
An intensive medication strategy should be considered for every patient. Patients with a poor-prognosis factor have more to gain from an intensive strategy.
Glucocorticoids should be tapered in patients who are in persistent remission. Tapering biologic DMARDs can be considered, especially when they are used with a synthetic DMARD.
In patients with a sustained, long-term remission, cautious down-titration of a synthetic DMARD can be considered as a shared decision between a patient and physician.
DMARD-naive patients with poor-prognosis markers can be considered for combination therapy with methotrexate and a biologic DMARD. (“This strategy is clearly not cost effective, but there is a subgroup for whom early treatment with methotrexate and a biologic could be advantageous,” Dr. Landewé said.)
When adjusting therapy, take into account factors beyond disease activity such as safety, comorbidities, and progression of structural damage.