Ann Rheum Dis 73:492-509 doi:10.1136/annrheumdis-2013-204573
  • Recommendation

EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2013 update

Open Access
  1. Désirée van der Heijde5
  1. 1Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Austria
  2. 22nd Department of Medicine, Hietzing Hospital Vienna, Vienna, Austria
  3. 3Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
  4. 4Atrium Medical Center, Heerlen, The Netherlands
  5. 5Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
  6. 6Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Chapel Allerton Hospital, Leeds, UK
  7. 7NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
  8. 8Department of Rheumatology and Clinical Immunology, Charité-University Medicine, Free University and Humboldt University, Berlin, Germany
  9. 9Clinical Immunology Free University and Humboldt University, Berlin, Germany
  10. 10Department of Rheumatology B, Cochin Hospital, René Descartes University, Paris, France
  11. 11Department of Rheumatology, Nîmes University Hospital, Montpellier I University, Nimes, France
  12. 12Rheumatology Department, Paris 06 UPMC University, AP-HP, Pite-Salpetriere Hospital, Paris, France
  13. 13Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
  14. 14Hospital Garcia de Orta, Almada, Portugal
  15. 15Oregon Health and Science University, Portland, Oregon, USA
  16. 16EULAR Standing Committee of People with Arthritis/Rheumatism in Europe (PARE), Zurich, Switzerland
  17. 17Department of Rheumatology and Clinical Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
  18. 18VU University Medical Center, Amsterdam, The Netherlands
  19. 19Service d'Immuno-Rhumatologie, Montpellier University, Lapeyronie Hospital, Montpellier, France
  20. 20Academic Clinical Unit of Rheumatology, Department of Internal Medicine, University of Genova, Genova, Italy
  21. 212nd Hospital Department, Institute of Rheumatology, University of Belgrade Medical School, Belgrade, Serbia
  22. 22Department of Rheumatology, Erasmus MC, University Medical Center, Dr Molewaterplein, Rotterdam, The Netherlands
  23. 23Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
  24. 24Hopitaux Universitaires Paris Sud, AP-HP, and Université Paris-Sud, Le Kremlin Bicetre, France
  25. 25Institute of Rheumatology and Clinic of Rheumatology, Charles University, Prague, Czech Republic
  26. 26Department of Rheumatology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
  27. 27Department of Internal Medicine, University of Cologne, Cologne, Germany
  28. 28King's College School of Medicine, Weston Education Centre, London, UK
  29. 29Jyväskylä Central Hospital, Jyväskylä, Finland
  30. 30Medcare Oy, Äänekoski, Finland
  31. 31Division of Clinical Decision Making, Informatics and Telemedicine, Tufts University School of Medicine, Boston, Massachusetts, USA
  1. Correspondence to Professor Josef S Smolen, Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Waehringer Guertel 18-20, Vienna A-1090, Austria; josef.smolen{at}
  • Received 7 September 2013
  • Revised 5 October 2013
  • Accepted 11 October 2013
  • Published Online First 25 October 2013


In this article, the 2010 European League against Rheumatism (EULAR) recommendations for the management of rheumatoid arthritis (RA) with synthetic and biological disease-modifying antirheumatic drugs (sDMARDs and bDMARDs, respectively) have been updated. The 2013 update has been developed by an international task force, which based its decisions mostly on evidence from three systematic literature reviews (one each on sDMARDs, including glucocorticoids, bDMARDs and safety aspects of DMARD therapy); treatment strategies were also covered by the searches. The evidence presented was discussed and summarised by the experts in the course of a consensus finding and voting process. Levels of evidence and grades of recommendations were derived and levels of agreement (strengths of recommendations) were determined. Fourteen recommendations were developed (instead of 15 in 2010). Some of the 2010 recommendations were deleted, and others were amended or split. The recommendations cover general aspects, such as attainment of remission or low disease activity using a treat-to-target approach, and the need for shared decision-making between rheumatologists and patients. The more specific items relate to starting DMARD therapy using a conventional sDMARD (csDMARD) strategy in combination with glucocorticoids, followed by the addition of a bDMARD or another csDMARD strategy (after stratification by presence or absence of adverse risk factors) if the treatment target is not reached within 6 months (or improvement not seen at 3 months). Tumour necrosis factor inhibitors (adalimumab, certolizumab pegol, etanercept, golimumab, infliximab, biosimilars), abatacept, tocilizumab and, under certain circumstances, rituximab are essentially considered to have similar efficacy and safety. If the first bDMARD strategy fails, any other bDMARD may be used. The recommendations also address tofacitinib as a targeted sDMARD (tsDMARD), which is recommended, where licensed, after use of at least one bDMARD. Biosimilars are also addressed. These recommendations are intended to inform rheumatologists, patients, national rheumatology societies and other stakeholders about EULAR's most recent consensus on the management of RA with sDMARDs, glucocorticoids and bDMARDs. They are based on evidence and expert opinion and intended to improve outcome in patients with RA.

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 3.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:

Open Access

Free sample This recent issue is free to all users to allow everyone the opportunity to see the full scope and typical content of ARD.
View free sample issue >>

Don't forget to sign up for content alerts so you keep up to date with all the articles as they are published.

Navigate This Article