What are the EULAR treatment guidelines for early rheumatoid arthritis (RA)?

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

In 2016, the European League Against Rheumatism (EULAR) updated its 2007 guidelines for the management of early arthritis, which put renewed emphasis on early intervention, preventive lifestyle measures, and careful clinical examination rather than reliance on ultrasound or advanced imaging. Key recommendations, based on evidence and expert opinion, are as follows [152] :

  • Within 6 weeks of the onset of symptoms, patients presenting with joint swelling associated with pain or stiffness should be referred to a rheumatologist (Level of evidence: Ib; grade of recommendation: B)

  • Clinical examination is the method of choice for detecting arthritis, which may be confirmed by ultrasonography (Level of evidence: IIb; grade of recommendation: C)

  • Patients should be started on disease-modifying antirheumatic drugs (DMARDs) as early as possible (ideally within 3 months), even if they do not fulfill classification criteria for an inflammatory rheumatologic disease (Level of evidence: Ia; grade of recommendation: A)

  • Methotrexate (MTX) is the preferred DMARD, unless contraindicated, and should be first-line treatment (Level of evidence: Ia; grade of recommendation: A)

  • Systemic glucocorticoids should be used at the lowest dose necessary as temporary (< 6 months) adjunctive treatment to reduce pain, swelling, and structural progression. Intra-articular glucocorticoid injections should be considered for the treatment of local symptoms of inflammation (Level of evidence: Ia; grade of recommendation: A)

  • Regular monitoring of disease activity, adverse events and comorbidities should guide decisions on choice and changes in treatment strategies to reach clinical remission (Level of evidence: Ib; grade of recommendation: A)

  • Arthritis activity should be assessed at intervals of 1 to 3 months until clinical remission has been reached. Monitoring should include tender and swollen joint counts, patient and physician global assessments, erythrocyte sedimentation rate, and C-reactive protein; radiographic and patient-reported outcome measures, such as functional assessments, can be used as complementary monitors. (Level of evidence: Ia; grade of recommendation: A)

  • Nonpharmacological interventions, such as dynamic exercises and occupational therapy, should be considered as adjuncts to drug treatment (Level of evidence: Ia; grade of recommendation: B)

  • Smoking cessation, dental care, weight control, assessment of vaccination status, and management of comorbidities should be included in overall patient care (Level of evidence: IIb; grade of recommendation: C)

  • Education programs aimed at coping with pain, disability, maintenance of ability to work, and social participation may be used as adjunct interventions (Level of evidence: Ia; grade of recommendation: B)


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