What are the ACR treatment guidelines for established rheumatoid arthritis (RA)?

Updated: Feb 07, 2020
  • Author: Howard R Smith, MD; Chief Editor: Herbert S Diamond, MD  more...
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In its 2015 revised guidelines, the ACR included the following recommendations for treatment of patients with established RA [4] :

  • A treat-to-target stategy should be used regardless of disease activity.  (Strong recommendation)
  • Low disease activity: DMARD monotherapy over TNF inhibitor; MTX is the preferred DMARD.  (Strong recommendation)
  • Moderate or high disease activity: Combination DMARDs or  add a TNF inhibitor, or  non-TNF biologic or  tofacitinib  (Strong recommendation)
  • Moderate/high disease activity despite TNF inhibitor therapy: Switch to a non-TNF biologic with or without MTX over another TNF inhibitor or  tofacitinib  (Strong recommendation)

A change from 2012 to 2015 guidelines is that 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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