What are the guidelines for managing rheumatoid arthritis?

Guidelines for Rheumatoid Arthritis Management

The management of rheumatoid arthritis should follow a treat-to-target approach with methotrexate as first-line therapy, followed by combination therapy or biologic agents for inadequate response, with the goal of achieving remission or low disease activity to prevent joint damage and improve quality of life. 1

Overarching Principles

• Treatment of RA patients should aim at the best care through shared decision-making between the patient and rheumatologist 1
• Rheumatologists are the specialists who should primarily care for RA patients 1
• RA treatment should consider the high individual, societal, and medical costs associated with the disease 1

Initial Treatment Strategy

• Therapy with DMARDs should be started as soon as the diagnosis of RA is made to prevent irreversible joint damage 1, 2
• Methotrexate (MTX) should be part of the first treatment strategy in patients with active RA, optimized to 20-25 mg weekly or maximum tolerated dose 1, 2
• In cases of MTX contraindications or early intolerance, sulfasalazine or leflunomide should be considered as alternative first-line therapy 1, 2
• Low-dose glucocorticoids should be considered as part of the initial treatment strategy (in combination with one or more csDMARDs) for up to 6 months, but should be tapered as rapidly as clinically feasible 1, 2

Monitoring and Treatment Targets

• Treatment should aim at reaching a target of remission or low disease activity in every patient 1
• Monitoring should be frequent in active disease (every 1-3 months); if there is no improvement by at most 3 months after treatment initiation or the target has not been reached by 6 months, therapy should be adjusted 1, 2
• Disease activity should be measured using validated instruments such as SDAI or CDAI to guide treatment decisions 1, 2

Treatment Escalation for Inadequate Response

• If the treatment target is not achieved with the first DMARD strategy and poor prognostic factors are absent, switching to another csDMARD strategy should be considered 1
• When poor prognostic factors are present (autoantibodies, high disease activity, early erosions, failure of 2 csDMARDs), addition of a biologic DMARD should be considered 1, 2
• Triple DMARD therapy (adding sulfasalazine and hydroxychloroquine to methotrexate) is an effective option before moving to biologic therapy 2
• In patients responding insufficiently to MTX and/or other csDMARD strategies, biologic DMARDs (TNF inhibitors, abatacept, tocilizumab, or rituximab) should be commenced with MTX 1
• If a first biologic DMARD fails, patients should be treated with another biologic DMARD; if a first TNF inhibitor therapy fails, patients may receive another TNF inhibitor or a biologic agent with another mode of action 1
• Janus kinase (JAK) inhibitors such as tofacitinib may be considered after biologic treatment has failed 1

Special Considerations

• For patients with liver disease, heart failure, lymphoproliferative disorders, previous serious infections, or nontuberculous mycobacterial lung disease, medication selection requires special consideration 1, 2
• Patients starting biologic therapy should be screened for tuberculosis and hepatitis B/C 1, 2
• Rituximab may be preferred in patients with history of lymphoma or demyelinating disease 1, 3
• Presence of rheumatoid factor, anti-citrullinated protein antibodies, or elevated serum IgG may predict better response to rituximab 2

Treatment Tapering and Long-term Management

• If a patient is in persistent remission after having tapered glucocorticoids, tapering biologic DMARDs can be considered, especially if this treatment is combined with a csDMARD 1
• In cases of sustained long-term remission, cautious reduction of the csDMARD dose could be considered, as a shared decision between patient and physician 1, 2
• Approximately 15-25% of patients may achieve sustained drug-free remission, particularly those with shorter symptom duration, absence of rheumatoid factor or anti-citrullinated protein antibodies, lower disease activity before remission, and less baseline disability 2

Common Pitfalls to Avoid

• Delaying DMARD initiation, which can lead to irreversible joint damage and worse long-term outcomes 2, 4
• Inadequate methotrexate dosing or insufficient duration of treatment trial before concluding treatment failure 2, 5
• Long-term glucocorticoid use without appropriate monitoring for adverse effects such as cataracts, osteoporosis, and cardiovascular disease 2
• Failure to adjust therapy when treatment targets are not met 1, 2
• Overlooking comorbidities that may influence treatment selection 1, 2
• Not considering the safety profile of DMARDs when used long-term, particularly regarding liver, kidney, and bone marrow toxicity 6