In a nutshell
This article presents the latest (2013) recommendations of the European League against Rheumatism (EULAR) for management of rheumatoid arthritis.
Some background
Rheumatoid arthritis (RA) is the most common form of chronic inflammatory arthritis (inflammation of the joints) and often results in joint damage and physical disability.
The management of RA rests primarily on the use of disease-modifying antirheumatic drugs (DMARDs). These agents can reduce signs and symptoms, disability, impaired quality of life, and joint damage. DMARDs form two major classes: synthetic chemical compounds (sDMARDs) and biological agents (bDMARDs).
Methotrexate is a synthetic DMARD, that is usually chosen as first-line therapy for RA. Other sDMARDs include sulphasalazine, hydroxychloroquine and leflunomide.
TNF inhibitors is a major class of bDMARDs. These include infliximab (Remicade), adalimumab (Humira),and etanercept (Enbrel).
Methods & findings
The main updates in the 2013 recommendations are:
1. Starting treatment as early as possible: therapy with DMARDs should be started as soon as the diagnosis of RA is made.
2. Treatment should be aimed at reaching a target of remission or low disease activity in every patient.
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.
4. Methotrexate should be part of the first treatment strategy in patients with active RA.
5. In cases where methotrexate cannot be used, sulfasalazine or leflunomide should be considered as part of the (first) treatment strategy.
6. In patients not previously treated with DMARDs, treatment should start with the synthetic ones, either alone or in combinations.
7. Low-dose glucocorticoids (e.g. prednisone) should be considered as part of the initial treatment strategy (in combination with one or more sDMARDs) for up to 6 months, but dose should be gradually reduced asap.
8. If the treatment target is not achieved with the first DMARD strategy, another sDMARD strategy should be considered. However, in patients with an aggressive disease the addition of a bDMARD should be considered.
9. In patients responding insufficiently to methotrexate and/or other sDMARD strategies, bDMARDs (TNF inhibitors or, under certain circumstances, rituximab) should be added.
10. If a first bDMARD has failed, patients should be treated with another bDMARD. If a first TNF inhibitor therapy has failed, patients may receive another TNF inhibitor or a biological agent with another mode of action.
11. Tofacitinib – a new drug of the janus kinase (JAK) inhibitor class – may be considered after biological treatment has failed.
12. If a patient is in persistent remission after stopping glucocorticoids, bDMARDs can also be discontinued gradually, especially if this treatment is combined with a sDMARD.
13. In cases of sustained long-term remission, cautious reduction of the sDMARD dose could be considered.
14. When therapy needs to be adjusted, factors apart from disease activity, such as progression of join damage in imaging, additional conditions and safety issues, should be taken into account.
Published By :
Annals of the rheumatic diseases
Date :
Mar 01, 2014
