In this study, the authors discussed several evidence-based treatment guidelines for rheumatoid arthritis (RA). These guidelines were meant to serve as a tool for clinicians to decide treatment options for patients. 

In RA, the immune system begins attacking healthy tissues the way it normally attacks viruses or bacteria. This can cause inflammation, leading to chronic pain. RA has significant negative impact on daily activities and quality of life. With development of new treatments for RA, the last guidelines established by American College of Rheumatology (ACR) in 2012 need to be updated on several categories. These are: use of traditional disease-modifying antirheumatic drugs (DMARDs), use of these drugs in RA patients with other diseases, and use of vaccines in RA patients, among others. 

The ACR have updated guidelines for the treatment options for RA. These guidelines do not address topics related to diagnosis, monitoring of disease activity or surgeries. The guidelines were based on Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. Based on this, a strong recommendation means that clinicians are certain that the treatment would be beneficial. A conditional recommendation means that there could be some uncertainty regarding the benefits over harm.

Strong recommendations for early RA

If the disease-activity score (DAS, an assessment to measure the progress and improvement of RA in multiple joints) is low, single treatment with methotrexate (Trexall) is preferred over combination treatment for those who were not previously treated with a DMARD. 

If the DAS is moderate or high, combination treatment is preferred. This could be combination of DMARDs or biological treatments (those that block activity of certain parts of the immune system).

Strong recommendations for established RA

 If the DAS is low, single treatment with methotrexate is preferred over combination therapy for those who were not previously treated with a DMARD.

If the DAS remains moderate or high, combination treatment is preferred. This could be combination of DMARDs with addition of biological treatments or tofacitinib (Xeljanz).

If the RA is in remission (no evidence of disease activity), treatment with DMARDs or biological treatments should be tapered off.

Recommendations for high-risk RA

There are several strong and conditional recommendations for RA patients with other disease conditions. These are heart failure, hepatitis C, and skin cancer among others. In these patients, DMARDs are generally recommended over treatments that block immune system activity.