Smolen et al., 2020

EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2019 update

At a glance

Objectives

To provide an update of the European League Against Rheumatism (EULAR) RA management recommendations to account for the most recent developments in the field.

Related articles

Treatment recommendations by the ACR (Fraenkel et al., 2021).

Link

DOI: https://doi.org/10.1136/annrheumdis-2019-216655

Methods

• Summarise new supporting or contradicting evidence for therapies
• Literature search and predefined voting process on current levels of evidence

Results

• Task force agreed on five overarching principles and 12 recommendations concerning use of csDMARDs (MTX, leflunomide, sulfasalizine), glucocorticoids (GCs), bDMARDs (TNFis), and tsDMARDs (JAKis)
• Guidance on monotherapy, combination therapy, treatment strategy (treat-to-target) and tapering on sustained clinical remission is provided
  1. Begin with MTX plus GCs and upon insufficient response within 3 to 6 months, stratify by risk factors
  2. In the presence of poor prognostic factors (autoantibodies, high disease activity, early erosions or failure of two csDMARDs), any bDMARD or JAKi should be added to the csDMARD
  3. Add a bDMARD (another or same class) or tsDMARD is recommended

Defining MTX failure

According to this definition, MTX treatment has been unsuccessful once a patient adds any bDMARD or JAKi. Classifying initial treatment success for MTX in SRQ should therefore look for the addition of other drugs and not the stopping date of MTX.

• On sustained remission, DMARDs may be tapered but not stopped
• Levels of agreement among experts were high mostly

Conclusion

WIP