EULAR's new rheumatoid arthritis treatment guidelines are comprehensive including recommendations for the use of everything from methotrexate to biosimilars.
The European League Against Rheumatism has updated its recommendations for the treatment of rheumatoid arthritis with the inclusion of synthetic, biologic and biosimilar disease-modifying anti-rheumatic drugs (DMARDs).
Led by Josef Smolen, M.D., and a 50-member international team of physicians, they offer four overarching principles and 12 recommendations based on three systematic literature reviews. The recommendations were published online March 6 in the Annals of the Rheumatic Diseases.
“The management of rheumatoid arthritis has changed dramatically over the past 30 years. The recommendations synthesize the current thinking on approaching rheumatoid arthritis treatment,” the authors wrote.
In rheumatoid arthritis, there are two targets for treatment - sustained remission or low disease activity. Anything other than those two responses should prompt a change in treatment. The best results for patients with rheumatoid arthritis typically comes through combinations of therapeutic agents and when one treatment fails there are options for rescue therapy which are spelled out in the recommendations.
Among some key points from the guidelines, methotrexate remains a “pivotal drug once the rheumatoid arthritis diagnosis has been made” and here, escalation of its dose is recommended as is combining it with newer disease modifying anti-rheumatic drugs (DMARDs). And, as compared to the 2013 update, conventional synthetic DMARDs combination therapy, with or without glucocorticoids, is no longer explicit.
The guidelines address glucocorticoid use and conventional synthetic DMARDs - specifically, methotrexate, leflunomide, sulfasalazine; and, biologic DMARDs - specifically, TNF inhibitors (adalimumab, certolizumab pegol, etanercept, golimumab and infliximab), abatacept, rituximab, tocilizumab, clazakizumab, sarilumab and sirukumab. They also include biosimilar DMARDs and targeted synthetic DMARDs (Janus kinase inhibitors tofacitinib and baricitinib).
As a first course of therapy, the task force recommends methotrexate (rapid escalation to 25 mg per week) plus short-term glucocorticoid with the goal of achieving 50 percent improvement within three months and achieving the target treatment goal within six months. But if these targets are not met, they suggest switching to or adding a conventional synthetic DMARD with short-term glucocorticoid.
Thirdly, if after trying two conventional synthetic DMARDs, autoantibodies are present with high disease activity and early erosion, it is recommended that a biologic DMARD or Jak-inhibitor be added to the conventional synthetic DMARD. If this fails, any other biologic DMARD or targeted synthetic DMARD is recommended. For patients in sustained remission, biologic DMARDs can be tapered.
Four Overarching Principles
Josef S Smolen, Robert Landewe, Johannes Bijlsma, et al. “EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2016 update,” Annals of the Rheumatic Diseases. 2017;0:1–18. doi:10.1136/annrheumdis-2016-210715