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      Drugs & Diseases > Rheumatology

      Rheumatoid Arthritis (RA) Guidelines

      Updated: Sep 05, 2023
      • Author: Sriya K M Ranatunga, MD, MPH, FACP, FACR; Chief Editor: Herbert S Diamond, MD  more...
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      Guidelines

      Guidelines Summary

      Classification and disease activity measures

      Updated guidelines on following aspects of rheumatoid arthritis (RA) management have been published:

      Treatment

      The ACR and EULAR regularly update their clinical practice guidelines on the pharmacologic management of RA. As general principles, guidelines from both organizations stress the importance of early initiation of therapy, shared decision making, and a treat-to-target approach, with frequent monitoring of treatment response. Both organizations offer similar recommendations on use of disease-modifying antirheumatic drugs (DMARDs). [4, 5]

      ACR recommendations for initiation of treatment in DMARD-naïve patients with moderate to high disease activity are as follows [4] :

      • Methotrexate monotherapy is strongly recommended over hydroxychloroquine or sulfasalazine; biologic DMARD (bDMARD) or targeted synthetic DMARD (tsMARD) monotherapy; or methotrexate plus a non–tumor necrosis factor (TNF) inhibitor bDMARD or tsDMARD
      • Methotrexate is conditionally recommended over leflunomide; dual or triple conventional synthetic DMARD (csDMARD) therapy; or the combination of methotrexate with a TNF inhibitor

      The ACR conditionally recommends against initiating short-term (< 3 mo) glucocorticoids along with a csDMARD, and strongly recommends against longer-term glucocorticoids.

      ACR recommendations for initiation of treatment in DMARD-naïve patients with low disease activity are as follows:

      • Hydroxychloroquine is conditionally recommended over other csDMARDs
      • Sulfasalazine is conditionally recommended over methotrexate
      • Methotrexate is conditionally recommended over leflunomide

      In patients with moderate to high disease activity who have been treated with csDMARDs other than methotrexate, the ACR conditionally recommends methotrexate monotherapy over the combination of methotrexate with a bDMARD or tsDMARD

      ACR treat-to target recommendations are as follows:

      • A minimal initial treatment goal of low disease activity is conditionally recommended over a goal of remission.
      • For patients taking oral methotrexate who are not at target, switching to subcutaneous methotrexate is conditionally recommended over adding or switching to alternative DMARD(s)
      • For patients taking maximally tolerated doses of methotrexate who are not at target, the addition of a bDMARD or tsDMARD is conditionally recommended over triple therapy (ie, addition of sulfasalazine and hydroxychloroquine).
      • For patients taking a bDMARD or tsDMARD who are not at target, switching to a bDMARD or tsDMARD of a different class is conditionally recommended over switching to a bDMARD or tsDMARD belonging to the same class.

      ACR recommendations regarding discontinuation of DMARD therapy are as follows:

      • For patients who are at target for at least 6 months, continuation of all DMARDs at their current dose is conditionally recommended over a dose reduction of a DMARD, dose reduction is conditionally recommended over gradual discontinuation of a DMARD, and gradual discontinuation is conditionally recommended over abrupt discontinuation of a DMARD.
      • Gradual discontinuation of sulfasalazine is conditionally recommended over gradual discontinuation of hydroxychloroquine for patients taking triple therapy who wish to discontinue a DMARD.
      • For patients taking methotrexate plus a bDMARD or tsDMARD who wish to discontinue a DMARD, gradual discontinuation of methotrexate is conditionally recommended over gradual discontinuation of the bDMARD or tsDMARD.

      The ACR guidelines also include specific recommendations for patients with the following:

      • Subcutaneous nodules
      • Pulmonary disease
      • Heart failure
      • Lymphoproliferative disorder
      • Hepatitis B infection
      • Nonalcoholic fatty liver disease (NAFLD)
      • Persistent hypogammaglobulinemia without infection
      • Previous serious infection

      EULAR guidelines include the following recommendations for DMARD use [5] :

      • Therapy with DMARDs should be started as soon as RA is diagnosed.
      • In every patient, the treatment target should be sustained remission or low disease activity.
      • Patients with active disease should receive monitoring every 1–3 months; if no improvement occurs within at most 3 months, or the target has not been reached by 6 months, therapy should be adjusted.
      • Methotrexate should be part of the initial treatment strategy . Leflunomide or sulfasalazine should be considered when methotrexate is contraindicated. If those three agents are contraindicated or not tolerated and the patient has early, mild disease (ie, without poor prognostic factors), hydroxychloroquine may be used.
      • Short-term use of glucocorticoids should be considered when initiating or changing csDMARDs, but should be tapered and discontinued as rapidly as clinically feasible.
      • If the treatment target is not achieved with the first csDMARD strategy and poor prognostic factors are absent, other csDMARDs should be considered. If poor prognostic factors are present, a bDMARD should be added; Janus kinase (JAK) inhibitors may be considered, but pertinent risk factors must be taken into account.
      • bDMARDs and tsDMARDs should be combined with a csDMARD; in patients who cannot use csDMARDs as co-medication, interleukin-6 (IL-6) pathway inhibitors and tsDMARDs may have some advantages compared with other bDMARDs.
      • If a bDMARD or tsDMARD has failed, treatment with another bDMARD or a tsDMARD should be considered; if a TNF or IL-6 receptor inhibitor therapy has failed,  an agent with another mode of action or a second TNF inhibitor or IL-6 receptor inhibitor may be used.
      • After glucocorticoids have been discontinued and the patient is in sustained remission, dose reduction of DMARDs may be considered.
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