EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2016 update

Journal article

Recent insights in RA necessitated updating the EULAR RA management recommendations. A large international Task Force based decisions on evidence from 3 systematic literature reviews, developing 4 overarching principles and 12 recommendations (versus 3 and 14, respectively, in 2013). The recommendations address conventional synthetic (cs) DMARDs (methotrexate [MTX], leflunomide, sulfasalazine); glucocorticoids (GC); biological (b) DMARDs (TNF-inhibitors [adalimumab, certolizumab pegol, etanercept, golimumab, infliximab], abatacept, rituximab, tocilizumab, clazakizumab, sarilumab and sirukumab and biosimilar (bs) DMARDs; targeted synthetic (ts) DMARDs (Janus kinase [Jak] inhibitors tofacitinib, baricitinib). Monotherapy, combination therapy, treatment strategies (treat-totarget) and the targets of sustained clinical remission, as defined by ACR-EULAR Boolean or index criteria, or low disease activity are discussed. Targeting imaging remission has no advantages, but economic disadvantages. Cost aspects were taken into consideration.

As first strategy, the Task Force recommends MTX (rapid escalation to 25mg/week) plus short-term GC, aiming at >50% improvement within 3- and target attainment within 6 months. If this fails stratification is recommended. Without unfavorable prognostic markers, switching to -or adding- another csDMARDs (plus short-term GC) is suggested. In the presence of unfavorable prognostic markers (autoantibodies, high disease activity, early erosions, failure of 2 csDMARDs), any bDMARD (current practice) or Jak inhibitor should be added to the csDMARD. If this fails, any other bDMARD or tsDMARD is recommended. If a patient is in sustained remission, bDMARDs can be tapered.

For each recommendation, levels of evidence and Task Force agreement are provided, both mostly very high. These recommendations intend informing rheumatologists, patients, national rheumatology societies, hospital officials, social security agencies and regulators about EULAR’s most recent consensus on the management of RA, aimed at attaining best outcomes with current therapies.

Authors: Smolen, J; Landewé, R; Bijlsma, J; Burmester, G; Chatzidionysiou, K

• Publication status: Published
• Peer review status: Peer reviewed
• Publisher: BMJ Publishing Group
• Journal: Annals of the Rheumatic Diseases
• Volume: 76
• Issue: 6
• Pages: 960-977
• Publication date: 2017-03-06
• Acceptance date: 2017-02-09
• DOI: 10.1136/annrheumdis-2016-210715
• EISSN: 1468-2060
• ISSN: 0003-4967