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EULAR Updates Recommendations for Management of RA With DMARDs
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The European League Against Rheumatism has updated its 2013 recommendations for the management of rheumatoid arthritis with disease-modifying antirheumatic drugs, according to a recently published report.
“In treatment-naïve patients we now recommend primarily using [methotrexate] MTX plus short-term glucocorticoids,” Josef S. Smolen, MD, in the Division of Rheumatology at the Medical University of Vienna, told Healio Rheumatology. “The recommendation to use combinations of [conventional synthetic] csDMARDs has been deleted and we now more strongly recommend combining with glucocorticoids ... For csDMARD combinations the data show that when MTX is combined with glucocorticoids, there is no advantage of also adding further csDMARDs like sulfasalazine [SSZ] or leflunomide or SSZ plus hydroxychloroquine, but adverse events are much more frequent.”
Smolen and colleagues used three systematic literature reviews to derive four principles and 12 recommendations compared with three principles and 14 recommendations in 2013.
As a first strategy to treat RA, EULAR recommends methotrexate — with rapid escalation to 25 mg/week — plus short-term glucocorticoids to achieve 50% improvement within 3 months and targeted attainment within 6 months.
If this first strategy fails, EULAR recommends the following stratification:
- without unfavorable prognostic markers, switch to or add another conventional synthetic DMARD (csDMARD) plus glucocorticoids;
- with unfavorable markers — which include autoantibodies, high disease activity, early erosions or failure of two csDMARDs — any biologic DMARD (bDMARD) or Janus kinase inhibitor should be added to the csDMARD; and
- for patients in sustained remission, bDMARDs can be tapered.
“For the latter, the previous notion on ‘low-dose short-term’ has been changed to ‘short-term’, since there are data that a single iv of 250mg (which is not low dose) leads to excellent results and also that 30mg prednisone daily tapered rapidly gives good outcomes,” Smolen said. – by Will Offit
Disclosures: The researchers report funding from EULAR. Please see the full study for a list of all other relevant financial disclosures.
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