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2016 update of the EULAR recommendations for the management of rheumatoid arthritis: a utopia beyond patients in low/middle income countries?
  1. Durga Prasanna Misra1,
  2. Vikas Agarwal1,
  3. Aman Sharma2,
  4. Anupam Wakhlu3,
  5. Vir Singh Negi4
  1. 1Department of Clinical Immunology, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Lucknow, India
  2. 2Cinical Immunology and Rheumatology Services, Department of Internal Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
  3. 3Department of Rheumatology, King George's Medical University, Lucknow, India
  4. 4Department of Clinical Immunology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
  1. Correspondence to
    Dr Durga Prasanna Misra, Department of Clinical Immunology, C block, 2nd floor, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Rae Bareily Road, Lucknow-226014, India; durgapmisra{at}, dpmisra{at}

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We read with great interest the recently published recommendations by the European League against Rheumatism (EULAR) on the management of rheumatoid arthritis (RA).1 The EULAR recommendations, although primarily targeted towards European countries, are read and followed across the world including low/middle income nations. Consequently, we were disappointed to note that the updated guidelines recommend the use of biological disease-modifying anti-rheumatic drugs (bDMARDs) or targeted synthetic DMARDs (tsDMARDs) immediately following failure of monotherapy with conventional synthetic DMARDs (csDMARDs) in those patients with poor prognostic factors such as seropositivity for rheumatoid factor (RF) or anticitrullinated peptide antibodies (ACPA), highly active disease or early radiographic joint damage (recommendation number 8).1 This is in contrast to the 2015 guidelines provided by the American College of Rheumatology (ACR) for the management of RA,2 which offer the option of either combining csDMARDs or using bDMARDs or tofacitinib (tsDMARD) following failure of methotrexate monotherapy in RA, irrespective of the presence or absence of such poor prognostic indicators. Early use of bDMARDs in the management of RA poses certain specific problems, as discussed below.

Rheumatoid arthritis is one of the …

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  • Contributors DPM, VA, VSN—conception and design of the paper. DPM, VA, AS, AW—acquisition of data, analysis and interpretation of data. DPM, VA—drafting the article. AS, AW, VSN—revising it critically for important intellectual content. DPM, VA, AS, AW, VSN—final approval of the version to be submitted.

  • Competing interests None declared.

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

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