What are the latest EULAR (European League Against Rheumatism) guidelines for treating rheumatoid arthritis?

EULAR 2019 Guidelines for Rheumatoid Arthritis Management

The 2019 EULAR recommendations for rheumatoid arthritis management emphasize early DMARD therapy immediately upon diagnosis, with methotrexate as the first-line treatment, aiming for sustained remission or low disease activity in all patients. 1

Overarching Principles

• Shared Decision Making: Treatment should aim at best care based on shared decision between patient and rheumatologist
• Treatment Considerations: Decisions based on disease activity, safety issues, and patient factors including comorbidities
• Specialist Care: Rheumatologists should primarily care for RA patients
• Multiple Treatment Options: Patients require access to multiple drugs with different modes of action
• Cost Considerations: Individual, medical, and societal costs should be considered in management

Treatment Algorithm

Initial Treatment

1. Start DMARDs immediately upon diagnosis (Level of Evidence 1a, Strength of Recommendation A) 1
2. Methotrexate (MTX) should be first-line therapy (LoE 1a, SoR A) 1
   • Optimal dosing: 7.5-25mg weekly 2
   • Consider subcutaneous administration for better bioavailability
3. If MTX contraindicated or early intolerance: Use leflunomide or sulfasalazine (LoE 1a, SoR A) 1
4. Add short-term glucocorticoids when initiating/changing csDMARDs
   • Various dose regimens and routes possible
   • Taper as rapidly as clinically feasible (LoE 1a, SoR A) 1

Monitoring and Treatment Adjustment

1. Monitor frequently in active disease (every 1-3 months)
2. Adjust therapy if:
   • No improvement within 3 months
   • Target not reached by 6 months (LoE 2b, SoR B) 1

Treatment Escalation

1. If target not achieved with first csDMARD:

   • Without poor prognostic factors: Consider other csDMARDs (LoE 5, SoR D) 1
   • With poor prognostic factors: Add bDMARD or tsDMARD (LoE 1a, SoR A) 1
     • Poor prognostic factors: RF/ACPA positivity (especially high levels), high disease activity, early joint damage, failure of 2 csDMARDs 1

2. bDMARDs and tsDMARDs should be combined with csDMARDs (LoE 1a, SoR A) 1

   • If csDMARDs cannot be used, IL-6 pathway inhibitors and JAK inhibitors may have advantages over other bDMARDs

3. If first bDMARD/tsDMARD fails:

   • Consider another bDMARD or tsDMARD
   • After TNF inhibitor failure, can use another TNF inhibitor or agent with different mode of action (LoE 1b, SoR A) 1

Treatment Tapering

1. If in persistent remission after tapering glucocorticoids:

   • Consider tapering bDMARDs or tsDMARDs (especially if combined with csDMARD) (LoE 1b, SoR A) 1

2. If in persistent remission:

   • Consider tapering csDMARD (LoE 2b, SoR B) 1

Important Clinical Considerations

Biologic DMARDs Options

• TNF inhibitors: Adalimumab, certolizumab pegol, etanercept, golimumab, infliximab
• T-cell costimulation modulator: Abatacept
• IL-6 pathway inhibitors: Tocilizumab, sarilumab
• B-cell depleting agent: Rituximab

Targeted Synthetic DMARDs

• JAK inhibitors: Tofacitinib, baricitinib, filgotinib, upadacitinib 3

Common Pitfalls to Avoid

1. Delayed DMARD initiation: Start immediately upon diagnosis to prevent irreversible joint damage
2. Inadequate MTX dosing: Ensure proper dosing and consider subcutaneous administration if oral not effective
3. Prolonged glucocorticoid use: Taper as rapidly as clinically feasible to minimize adverse effects
4. Infrequent monitoring: Regular assessment is crucial for timely treatment adjustments
5. Failure to adjust therapy promptly: Change treatment if no improvement by 3 months or target not reached by 6 months
6. Not considering tapering in sustained remission: Consider tapering to minimize exposure to potential side effects

Special Considerations

• Monotherapy: In patients who cannot use csDMARDs, IL-6 inhibitors and JAK inhibitors may have advantages 1
• Comorbidities: Always consider patient-specific factors when selecting therapy
• Persistent disease: Multiple successive drug options are often needed to reach therapeutic goals 1

The 2019 EULAR recommendations provide a comprehensive, evidence-based approach to RA management with the goal of achieving sustained remission or low disease activity in all patients through early intervention and strategic treatment escalation.