EULAR: Taper, discontinue glucocorticoids in rheumatoid arthritis as soon as feasible
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The 2022 EULAR recommendations for the management of rheumatoid arthritis are largely similar to the 2019 updates, with one point of emphasis being the importance of rapid glucocorticoid reduction and discontinuation.
“More evidence supports the recommendation to start methotrexate plus glucocorticoids, since this is not surpassed by several biologics plus methotrexate,” Josef S. Smolen, MD, of Vienna General Hospital, told attendees during the EULAR 2022 Congress on behalf of the global task force investigating the recommendations. “The necessity of rapid glucocorticoid dose reduction and discontinuation is more clearly emphasized.”
When preparing the new set of recommendations for the management of RA, Smolen and colleagues on the taskforce paid special attention any drugs that may have completed new phase 3 trials. Additionally, the investigators considered new information stemming from patient perspectives and any new safety concerns that may have surfaced in the time since the last review, Smolen said.
All five of the overarching principles, and six of the 12 recommendations, put forth in the 2019 update remain unchanged. The 2022 iteration holds a total of 11 recommendations.
The biggest change among recommendations from 2019 concerns the use of glucocorticoids as part of a first-line strategy for patients with RA. The new recommendation states that short-term glucocorticoids can be used in conjunction with conventional synthetic disease-modifying anti-rheumatic drugs, but that they should be tapered and stopped as soon as possible.
Other new changes introduced in the 2022 recommendations include:
If patients demonstrate a presence of poor prognostic factors, and the first conventional synthetic DMARD failed to help them reach the treatment target, a biologic DMARD should be added. Additionally, Janus kinase inhibitors may be considered, but managers should carefully weigh relevant risk factors.
Biologic DMARDs and targeted synthetic DMARDs should be used in concert with conventional synthetic DMARDs, but when patients cannot receive conventional synthetic DMARDs as a comedication, interleukin-6 pathway inhibitors and targeted synthetic DMARDs can be used.
If a biologic DMARD or targeted synthetic DMARD failed the patient, consider treating with a different biologic DMARD or targeted synthetic DMARD. If TNF inhibitors or IL-6 receptor therapy fails, it may be appropriate to use a drug with a different method of action or a second TNF or IL-6 receptor inhibitor.
Following the successful discontinuation of glucocorticoids, the reduction of DMARDs may be considered if the patient has reached continued remission.
“Most of the recommendations of the 2019 update remain unchanged,” Smolen said. “All five overarching principles, and six of the 12 individual items, which we reduced to 11, so it is more than half.”
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Smolen JS. EULAR recommendations for the management of rheumatoid arthritis – 2022 update. Presented at: EULAR 2022 Congress; June 1-4, 2022 (virtual meeting).
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