What are the EULAR guidelines on the use of DMARDs for the treatment of rheumatoid arthritis (RA)?

Updated: Feb 07, 2020
  • Author: Howard R Smith, MD; Chief Editor: Herbert S Diamond, MD  more...
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Answer

Guidelines from the European League Against Rheumatism (EULAR) on the use of disease-modifying antirheumatic drugs (DMARDs) in patients with rheumatoid arthritis (RA) were updated in 2019. Recommendations include the following [5] :

  • Therapy with DMARDs should be started as soon as the diagnosis of RA is made.
  • Treatment should be aimed at reaching a target of sustained remission or low disease activity in every patient.
  • Patients with active disease should have frequent monitoring (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.    
  • Methotrexate (MTX) should be part of the first treatment strategy.
  • In patients with a contraindication to MTX (or early intolerance), leflunomide or sulfasalazine should be considered as part of the first-line treatment strategy.
  • Short-term glucocorticoids should be considered when initiating or changing the dose of a conventional synthetic DMARDs (csDMARD); different dose regimens and routes of administration may be used for glucocorticoids, but the drugs should be tapered as rapidly as clinically feasible.            
  • If the treatment target is not achieved with the first csDMARD strategy, in the absence of poor prognostic factors, other csDMARDs should be considered.
  • If the treatment target is not achieved with the first csDMARD strategy, when poor prognostic factors are present, a biologic DMARD or a targeted synthetic DMARDs (currently, Janus kinase inhibitors) should be added.
  • Biologic DMARDs or targeted synthetic DMARDs should be combined with a csDMARD; in patients who cannot use csDMARDs as comedication, interleukin-6 (IL-6) pathway inhibitors and targeted synthetic DMARDs may have some advantages compared with other biologic DMARDs.
  • If a biologic DMARD or targeted synthetic DMARD has failed, treatment with another biologic or targeted synthetic DMARD should be considered; if one tumor necrosis factor (TNF) inhibitor therapy has failed, patients may receive an agent with another mode of action or a second TNF inhibitor.
  • If a patient is in persistent remission after having tapered glucocorticoids, one can consider tapering biologic or targeted synthetic DMARDs, especially if this treatment is combined with a csDMARD.
  • If a patient is in persistent remission, tapering the csDMARD could be considered.

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