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EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs
  1. Josef S Smolen1,2,
  2. Robert Landewé3,
  3. Ferdinand C Breedveld4,
  4. Maxime Dougados5,
  5. Paul Emery6,
  6. Cecile Gaujoux-Viala5,7,
  7. Simone Gorter3,
  8. Rachel Knevel4,
  9. Jackie Nam6,
  10. Monika Schoels2,
  11. Daniel Aletaha1,
  12. Maya Buch6,
  13. Laure Gossec5,
  14. Tom Huizinga4,
  15. Johannes W J W Bijlsma8,
  16. Gerd Burmester9,
  17. Bernard Combe10,
  18. Maurizio Cutolo11,
  19. Cem Gabay12,
  20. Juan Gomez-Reino13,
  21. Marios Kouloumas14,
  22. Tore K Kvien15,
  23. Emilio Martin-Mola16,
  24. Iain McInnes17,
  25. Karel Pavelka18,
  26. Piet van Riel19,
  27. Marieke Scholte14,
  28. David L Scott20,
  29. Tuulikki Sokka21,
  30. Guido Valesini22,
  31. Ronald van Vollenhoven23,
  32. Kevin L Winthrop24,
  33. John Wong25,
  34. Angela Zink26,
  35. Désirée van der Heijde4
  1. 1Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Austria
  2. 22nd Department of Medicine, Hietzing Hospital, Vienna, Austria
  3. 3Department of Internal Medicine/Rheumatology, University Hospital Maastricht, Maastricht, The Netherlands
  4. 4Department of Rheumatology, Leiden University Medical Centre, Leiden, The Netherlands
  5. 5Rheumatology B Department, Paris Descartes University, Cochin Hospital, Paris, France
  6. 6Section of Musculoskeletal Disease, Leeds Institute of Molecular Medicine, University of Leeds, Leeds, UK
  7. 7Pierre et Marie Curie University-Paris VI, APHP, Rheumatology, Pitié-Salpétrière Hospital, Paris, France
  8. 8Department of Rheumatology and Clinical Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
  9. 9Department of Rheumatology and Clinical Immunology, Humboldt University, Charité Hospital, Berlin, Germany
  10. 10Service d'Immuno-Rhumatologie, Montpellier University, Lapeyronie Hospital, Montpellier, France
  11. 11Academic Clinical Unit of Rheumatology, Department of Internal Medicine, University of Genova, Genova, Italy
  12. 12Division of Rheumatology, University Hospitals, Geneva, Switzerland
  13. 13Santiago University Clinical Hospital, Santiago University School of Medicine, Santiago de Compostela, Spain
  14. 14EULAR Standing Committee of People with Arthritis/Rheumatism in Europe, Zurich, Switzerland
  15. 15Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
  16. 16La Paz Hospital, Madrid, Spain
  17. 17University of Glasgow, Glasgow, UK
  18. 18Institute of Rheumatology and Clinic of Rheumatology, Charles University, Prague, Czech Republic
  19. 19Department of Rheumatology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
  20. 20King's College School of Medicine, Weston Education Centre, London, UK
  21. 21Department of Rheumatology, Jyväskylä Central Hospital, Jyväskylä, Finland
  22. 22Rheumatology Unit, Department of Clinical Medicine and Medical Therapy, Sapienza Università di Roma, Rome, Italy
  23. 23Rheumatology Unit, Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Solna, Sweden
  24. 24Oregon Health and Science University, Portland, Oregon, USA
  25. 25Division of Clinical Decision Making, Informatics and Telemedicine, Tufts University School of Medicine, Boston, Massachusetts, USA
  26. 26German Rheumatism Research Centre and Charité University Medicine, Berlin, Germany
  1. Correspondence to Professor Josef S Smolen, Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Waehringer Guertel 18–20, A-1090 Vienna, Austria; josef.smolen{at} or josef.smolen{at}


Treatment of rheumatoid arthritis (RA) may differ among rheumatologists and currently, clear and consensual international recommendations on RA treatment are not available. In this paper recommendations for the treatment of RA with synthetic and biological disease-modifying antirheumatic drugs (DMARDs) and glucocorticoids (GCs) that also account for strategic algorithms and deal with economic aspects, are described. The recommendations are based on evidence from five systematic literature reviews (SLRs) performed for synthetic DMARDs, biological DMARDs, GCs, treatment strategies and economic issues. The SLR-derived evidence was discussed and summarised as an expert opinion in the course of a Delphi-like process. Levels of evidence, strength of recommendations and levels of agreement were derived. Fifteen recommendations were developed covering an area from general aspects such as remission/low disease activity as treatment aim via the preference for methotrexate monotherapy with or without GCs vis-à-vis combination of synthetic DMARDs to the use of biological agents mainly in patients for whom synthetic DMARDs and tumour necrosis factor inhibitors had failed. Cost effectiveness of the treatments was additionally examined. These recommendations are intended to inform rheumatologists, patients and other stakeholders about a European consensus on the management of RA with DMARDs and GCs as well as strategies to reach optimal outcomes of RA, based on evidence and expert opinion.

This paper is freely available online under the BMJ Journals unlocked scheme, see

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  • JSS and RL are joint first authors.

  • Funding EULAR.

  • Competing interests The following authors declare that they have no potential conflict of interest: CG-V, SG, RK, MK, JN, MS, JW. The following authors declare a potential conflict of interest having received grant support and/or honoraria for consultations and/or for presentations as indicated; JSS: Abbott, Amgen, BMS, Centocor, Pfizer, Roche, Schering-Plough,UCB, Sanofi-Aventis, Wyeth; RL: Abbott, Amgen, BMS, Centocor, Merck, Pfizer, Schering-Plough, UCB, Wyeth; FCB: Abbott, Schering-Plough, Wyeth; MD: Pfizer, Wyeth, Abbott, Roche, Novartis, Nordic Pharma, BMS, UCB; PE: Abbot, BMS, Centocor, Pfizer, Roche, Schering-Plough,UCB, Sanofi-Aventis, Wyeth; MS: Abbott; DA: Abbott, Roche, Schering-Plough, BMS, UCB, Sanofi-Aventis; MB: Roche, Abbott, BMS, Wyeth; LG: Abbott, Schering-Plough, Roche, UCB, BMS, Wyeth; TH: Schering Plough, BMS, Biotest, Wyeth, Novartis, Roche, Sanofi-Aventis, Abbott, Axis-Shield; JWJWB: Abbott, Roche, Wyeth, Schering Plough, Merck, Pfizer, UCB, BMS; GB: Abbott, Wyeth, Schering-Plough, Roche and UCB; BC: Abbott,BMS, Roche, Schering, UCB,Wyeth; MC: Sanofi-Aventis, BMS, Pfizer, Abbott; CG: Roche, BMS, Abbott, Essex, Wyeth, UCB; JG-R: Abbott, BMS, Pfizer, Roche, Schering-Plough,Wyeth and UCB; TKK: Abbott, BMS, Roche, Schering-Plough,Wyeth, Pfizer, MSD and UCB; EMM: Wyeth/Pfizer, Roche, Abbott Schering Plough/MSD; IM: Schering Plough, Pfizer, Roche and BMS; KP: Roche, Abbott, BMS, Pfizer, MSD; PvR: Abbott, BMS, Roche, Sanofi-Aventis, Schering-Plough, UCB, Wyeth; DLS: MSD, Pfizer, Novartis, Roche, Wyeth, Novartis, Schering Plough; TS: Abbott, Pfizer, Sanofi-Aventis, Roche, UCB; GV: Abbott, BMS, Roche, Sanofi-Aventis, Schering-Plugh, UCB, Wyeth; RvV: Abbott, Pfizer/Wyeth, Roche, Schering-Plough, BMS, UCB; KLW: Amgen, Wyeth, UCB, Genentech; AZ: Abbott, Amgen, BMS, Essex/Schering-Plough, Merck, Pfizer, Roche, Sanofi, UCB, Wyeth; DvdH: Abbott, Amgen, BMS, Centocor, Chugai, Merck, Pfizer, Roche, Schering-Plough,UCB, Wyeth. Francis Berenbaum was the Handling Editor.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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