Rheumatoid Arthritis Initial Treatment
Start methotrexate immediately upon diagnosis of rheumatoid arthritis, combined with short-term low-dose glucocorticoids as bridging therapy, and escalate treatment rapidly if remission or low disease activity is not achieved within 3-6 months. 1, 2
First-Line Treatment Strategy
Methotrexate is the anchor drug and must be initiated as soon as RA is diagnosed, ideally within 3 months of symptom onset. 1, 2 This recommendation carries the highest level of evidence (1a, Grade A) with near-universal agreement among rheumatologists (9.4/10). 1
Methotrexate Dosing and Administration
- Use effective doses of methotrexate (oral or subcutaneous) with folic acid supplementation 3
- The goal is to reach therapeutic doses rapidly to achieve disease control 4, 3
Glucocorticoid Bridging Therapy
Add short-term low-dose glucocorticoids (≤10 mg/day prednisone equivalent) for up to 6 months as bridging therapy until methotrexate becomes effective, typically 6-12 weeks. 1, 2 Glucocorticoids should be tapered as rapidly as clinically feasible to minimize long-term adverse effects. 1
Alternative First-Line Options
If methotrexate is contraindicated or not tolerated early, substitute with leflunomide or sulfasalazine as part of the first treatment strategy. 1, 2 This recommendation also carries high-level evidence (1a, Grade A). 1
For patients with chronic kidney disease specifically, sulfasalazine is the preferred conventional synthetic DMARD when biologics are not immediately available. 5
Treatment Targets and Monitoring
The treatment target is sustained remission or, if unachievable, low disease activity. 1, 2 This treat-to-target approach is supported by the highest level of evidence (1a, Grade A). 1
Monitoring Schedule
- Monitor disease activity every 1-3 months during active disease using validated composite measures such as DAS28, SDAI, or CDAI 1, 2
- Assessment should include tender and swollen joint counts, patient and physician global assessments 2
Treatment Adjustment Timeline
If there is no improvement by 3 months or the target has not been reached by 6 months, therapy must be adjusted. 1, 2 This is a critical decision point that determines escalation strategy.
Treatment Escalation Algorithm
Without Poor Prognostic Factors
If the treatment target is not achieved with methotrexate (with or without other conventional synthetic DMARDs) and poor prognostic factors are absent, switch to another conventional synthetic DMARD strategy. 1
With Poor Prognostic Factors
When poor prognostic factors are present (high disease activity, positive rheumatoid factor/anti-CCP antibodies especially at high levels, or early joint damage), add a biologic DMARD or targeted synthetic DMARD (JAK inhibitor) to the conventional synthetic DMARD. 1, 2 This recommendation has the highest level of evidence (1a, Grade A). 1
Biologic Options
Available biologics include TNF inhibitors (adalimumab, certolizumab pegol, etanercept, golimumab, infliximab), abatacept, rituximab, sarilumab, and tocilizumab. 1
Biologics and targeted synthetic DMARDs should be combined with a conventional synthetic DMARD (typically methotrexate). 1 However, in patients who cannot use conventional synthetic DMARDs as comedication, IL-6 pathway inhibitors and JAK inhibitors may have advantages compared with other biologics. 1
Adjunctive Interventions
Non-Pharmacological Management
- Dynamic exercises and occupational therapy should be considered as adjuncts to drug treatment 2
- Smoking cessation, dental care, weight control, vaccination status assessment, and comorbidity management are essential components of overall care 2
NSAIDs
Use NSAIDs only at the minimum effective dose for the shortest time possible after evaluating gastrointestinal, renal, and cardiovascular risks. 2 NSAIDs provide symptomatic relief but do not modify disease progression.
Critical Pitfalls to Avoid
Do not delay DMARD initiation—therapy must start as soon as RA is diagnosed. 1, 2 Earlier treatment with disease-modifying agents is associated with better long-term outcomes. 4, 6
Do not continue ineffective therapy beyond 3-6 months—this represents a critical window for treatment adjustment. 1
Do not use long-term glucocorticoids—they should be tapered rapidly due to cumulative side effects. 2 The 2019 EULAR guidelines emphasize that glucocorticoids are bridging therapy only. 1
Do not start biologics as monotherapy in most cases—they should be combined with methotrexate or another conventional synthetic DMARD for optimal efficacy. 1
Specialty Care Requirement
Rheumatologists should primarily care for patients with RA as they possess optimal expertise regarding DMARD use, efficacy outcomes, risk assessment, and comorbidity management. 1 This principle received near-perfect agreement (9.9/10) in the EULAR recommendations. 1
Shared Decision-Making
Treatment decisions must be based on shared decision-making between patient and physician, considering disease activity, safety issues, and patient factors such as comorbidities. 1 This overarching principle is fundamental to modern RA management.