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Updated EULAR guidelines on treatment of rheumatoid arthritis, now published in the society's journal, advocate combination treatment, state reservations about tofacitinib, and declare a new preference for glucocorticoids in all combinations while withdrawing a preference for TNF inhibitors as second-line therapy.
Heralded with an announcement last July and posted online last October, the latest revision of the 2010 EULAR guidelines on treatment of rheumatoid arthritis are now published in print in the EULAR journal, Annals of the Rheumatic Diseases.
In comparison with the 2010 recommendations, this update
• deemed combination therapy of conventional disease modifying anti-rheumatic drugs (DMARDs) to be as acceptable as methotrexate (MTX) monotherapy for first-line treatment, advising combination treatment;
• did not advocate biologicals as monotherapy or part of first-line treatment;
• stated a preference for glucocorticoids as an element of all combinations;
• withdrew its preference for TNF inhibitors as second-line strategy for patients with adverse prognosis, advocating a combination of biological and conventional DMARDs instead;
• acknowledged that currently approved biosimilars appear to be as effective and safe as the original drugs they copy;
• approved the option of tapering biologicals for a patient off glucocorticoids and in persistent remission, “especially if” a conventional DMARD is continued (based on more evidence than was available in 2010); and
• strongly supported use of biologicals rather than tofacitinib, which it described as not a biological but a synthetic molecule targeting a specific pathway. Its reservations about tofacitinib related to its high cost, uncertainties about long-term adverse events, and the known efficacy of existing biologicals as alternatives. The revision says that tofacitinib “may be considered” after biologicals have failed.
(The update was completed last year before the European Medicines Agency had considered tofactitinib and elected not to approve it for rheumatoid arthritis.)