What is the best course of action for a patient with rheumatoid arthritis (RA) experiencing a flare while being treated with Symponi (golimumab)?

Management of RA Flare on Symponi (Golimumab)

Immediate Flare Management

For a patient experiencing an RA flare while on Symponi, immediately initiate short-term systemic glucocorticoids at ≤10 mg/day prednisone equivalent for less than 3 months to bridge until DMARD optimization takes effect. 1

• If the flare predominantly involves a single joint, use intra-articular glucocorticoid injection for targeted relief rather than systemic steroids 1
• Glucocorticoids should be used at the lowest possible dose and shortest duration (less than 3 months) because after 1-2 years, the risks of cataracts, osteoporosis, fractures, and cardiovascular disease outweigh benefits 1

Assess Disease Activity and Optimize Current Therapy

Before switching biologics, you must first optimize methotrexate to 20-25 mg/week (or maximum tolerated dose) before declaring treatment failure. 1

• Measure disease activity using validated indices: SDAI >11 or CDAI >10 indicates moderate-to-high activity requiring aggressive escalation 1
• Check inflammatory markers (CRP, ESR) and autoantibodies (rheumatoid factor, anti-CCP) to guide therapy selection 1
• Reassess disease activity every 1-3 months during active disease—if no improvement by 3 months after treatment change, adjust therapy immediately rather than waiting for 6-month maximal effect 1

Escalation Strategy if Optimization Fails

If methotrexate optimization fails to achieve low disease activity, add sulfasalazine and hydroxychloroquine to create triple-DMARD therapy before switching biologics. 1

• If triple-DMARD therapy still fails to control disease activity, add a biologic DMARD or targeted synthetic DMARD rather than continuing to adjust conventional DMARDs 1

Biologic Switching Strategy

If golimumab (Symponi) fails despite optimal DMARD therapy, switch to a different mechanism of action rather than trying another TNF inhibitor. 1

• Options include:
  • Tocilizumab (IL-6 receptor antagonist) 1
  • Abatacept (T-cell costimulation modulator) 1
  • Rituximab (anti-CD20) 1
• Do not switch to another TNF inhibitor after first TNF inhibitor failure—change mechanism of action instead 1

Treatment Targets

Target remission (SDAI ≤3.3, CDAI ≤2.8) or low disease activity (SDAI ≤11, CDAI ≤10) as the treatment goal. 1

• Aim for >50% improvement within 3 months of any treatment change 2
• The target must be attained within 6 months 2

Critical Pitfalls to Avoid

• Do not use long-term glucocorticoids (>1-2 years) as adverse effects outweigh benefits 1
• Do not underdose methotrexate—must reach 20-25 mg/week before concluding inadequate response 1
• Do not delay treatment intensification—flares are associated with radiographic progression and functional deterioration both during the flare and long-term, with a dose-response effect (the more flares, the worse the outcomes) 3
• Intensifying treatment during a flare outweighs the risk of possible overtreatment, as flares lead to irreversible joint damage progression 3