What are the ACR recommendations for the use of DMARDS in 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

This section summarizes the 2015 ACR recommendations for the use of nonbiologic and biologic DMARDs in the treatment of RA (see Table below). [4, 68] The ACR recommends that low disease activity or remission be the target for all patients with early or established disease who are receiving a DMARD or a biologic agent.

Table 1. 2015 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis (Open Table in a new window)

Disease Activity

Recommendations

Early RA (<6 months)

  • Administer DMARD monotherapy in patient with low-high disease activity
  • If disease activity remains moderate /high despite DMARD monotherapy, use combination DMARDs or  a TNF inhibitor or a non-TNF biologic

(Notable change from 2012 to 2015 guidelines: The 2015 guidelines do not recommend initial combination DMARD therapy in early RA with moderate to high disease activity)

Established RA (=6 month or meets 1987 ACR RA classification criteria)

If disease activity remains moderate or high despite DMARD monotherapy, ACR guidelines recommend one of the following:

  • Combination DMARDs
  • Add an anti-TNF biologic
  • Non-TNF biologic
  • Tofacitinib

  

If disease activity remains moderate or high despite use of a single anti-TNF biologic:

  • Switch to a non-TNF biologic  with or without MTX over another anti-TNFi or Tofacitinib

If disease activity remains moderate or high despite use of one anti-TNF biologic and one non-TNF biologic:

  • Use another non-TNF biologic with or without MTX over Tofacitinib
  • If still uncontrolled use Tofacitinib

(Notable change from 2012 to 2015 guidelines: Instead of switching from one anti-TNF biologic to another anti-TNF biologic because of continued activity, it is recommended to change first to a non-TNF biologic)

 

 


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