Overarching principles | LoE | SoR | LoA | |
A | Treatment of patients with RA should aim at the best care and must be based on a shared decision between the patient and the rheumatologist. | n.a. | n.a. | 9.7 |
B | Treatment decisions are based on disease activity, safety issues and other patient factors, such as comorbidities and progression of structural damage. | n.a. | n.a. | 9.8 |
C | Rheumatologists are the specialists who should primarily care for patients with RA. | n.a. | n.a. | 9.9 |
D | Patients require access to multiple drugs with different modes of action to address the heterogeneity of RA; they may require multiple successive therapies throughout life. | n.a. | n.a. | 9.9 |
E | RA incurs high individual, medical and societal costs, all of which should be considered in its management by the treating rheumatologist. | n.a. | n.a. | 9.4 |
Recommendations | ||||
1. | Therapy with DMARDs should be started as soon as the diagnosis of RA is made. | 1a | A | 9.8 |
2. | Treatment should be aimed at reaching a target of sustained remission or low disease activity in every patient.* | 1a | A | 9.7 |
3. | Monitoring should be frequent in active disease (every 1–3 months); if there is no improvement by at most 3 months after the start of treatment or the target has not been reached by 6 months, therapy should be adjusted. | 2b | B | 9.3 |
4. | MTX should be part of the first treatment strategy. | 1a | A | 9.4 |
5. | In patients with a contraindication to MTX (or early intolerance), leflunomide or sulfasalazine should be considered as part of the (first) treatment strategy. | 1a | A | 9.0 |
6. | Short-term glucocorticoids should be considered when initiating or changing csDMARDs, in different dose regimens and routes of administration, but should be tapered as rapidly as clinically feasible. | 1a | A | 8.9 |
7. | If the treatment target is not achieved with the first csDMARD strategy, in the absence of poor prognostic factors*, other csDMARDs should be considered. | 5 | D | 8.4 |
8. | If the treatment target is not achieved with the first csDMARD strategy, when and poor prognostic factors* are present, a bDMARD† or a tsDMARD‡ should be added. | 1a | A | 9.3 |
9. | bDMARDs and tsDMARDs should be combined with a csDMARD; in patients who cannot use csDMARDs as comedication, IL-6 pathway inhibitors and tsDMARDs may have some advantages compared with other bDMARDs. | 1a | A | 8.9 |
10. | If a bDMARD# or tsDMARD## has failed, treatment with another bDMARD† or a tsDMARD‡ should be considered; if one TNF inhibitor therapy has failed, patients may receive an agent with another mode of action or a second TNF inhibitor. |
#1b ##5 | A D | 8.9 |
11. | If a patient is in persistent remission after having tapered glucocorticoids, one can consider tapering bDMARDs or tsDMARDs, especially if this treatment is combined with a csDMARD. | 1b | A | 9.2 |
12. | If a patient is in persistent remission, tapering the csDMARD could be considered. | 2b | B | 9.0 |
*For definitions of remission, low disease activity and poor prognostic factors, see table 1.
†Abatacept, rituximab, sarilumab, tocilizumab and TNF inhibitors: adalimumab, certolizumab pegol, etanercept, golimumb,infliximab (whether boDMARDs or EMA-approved/FDA-approved bsDMARDs).
‡Janus kinase inhibitors.
bDMARDs, biological DMARDs; boDMARDs, biological originator DMARDs; bsDMARD, biosimilar DMARDs; csDMARDs, conventional synthetic DMARDs; DMARDs, disease-modifying antirheumatic drugs; EMA, European Medicines Agency; EULAR, European League Against Rheumatism; FDA, Food and Drug Administration; IL-6, interleukin 6; JAK, Janus kinase; LoA, levels of agreement; LoE, levels of evidence (according to the standards of the Oxford Centre for Evidence Based Medicine); MTX, methotrexate; n.a., not applicable; RA, rheumatoid arthritis; SoR, strengths of recommendation; TNF, tumour necrosis factor; tsDMARDs, targeted synthetic DMARDs (currently Janus kinase inhibitors).