The European League Against Rheumatism (EULAR) has released updated recommendations for the management of RA. According to this latest guidance, treatment with disease-modifying anti-rheumatic drugs (DMARDs) should be initiated as soon as a diagnosis of RA is made, with the aim of reaching a target of remission or low disease activity in every patient.
As first-line treatment, EULAR recommends rheumatologists administer methotrexate (MTX) or combination therapy of MTX with other conventional synthetic DMARDs. Low-dose glucocorticoids should also be considered in combination with DMARDs for up to six months, but should be tapered as soon as clinically feasible.
“These recommendations were based on three extensive literature reviews of the efficacy and safety of biological and conventional DMARDs, and address a number of common misinterpretations of the 2010 guidelines,” according to Professor Josef Smolen, Medical University of Vienna and Hietzing Hospital, Vienna. “As already stated in 2010, by advocating the use of synthetic DMARDs, rather than biologics, as the first-line treatment this approach avoids the over-treatment of 20-50% of patients with early RA, who will achieve the treatment target with such initial therapy” he concluded for the Task Force.
However, in patients failing to respond to this treatment within 6 months and when poor prognostic factors are present, biological DMARDs (TNF-inhibitors, abatacept or tocilizumab – or under certain circumstances rituximab) should be administered in combination with MTX.
The document further recommends that patients who have failed to respond to an initial biologic DMARD should receive another biologic DMARD. Patients who have failed to respond to an initial TNF-inhibitor may receive another TNF-inhibitor, or a biologic with an alternative mode of action. If biologic treatment has failed, tofacitinib may be considered where approved.
“Although the European Medicines Agency has not approved tofacitinib hitherto, it has been approved by the US Food and Drug Administration as well as in Japan and Russia. Having weighed up the evidence, the Task Force is convinced of its efficacy on clinical outcomes, function and structure. However, until more safety data are available and efficacy judged in clinical practice, tofacitinib is only recommended after at least one biological has failed – in fact, many Task Force members felt it should be used after two biological treatment failures,” concluded Professor Smolen.
If a patient has achieved persistent remission, and after having tapered glucocorticoids, clinicians should consider tapering the biological DMARD, particularly if the treatment is in combination with a conventional synthetic DMARD. In cases of sustained long-term remission, cautious dose-reduction of conventional synthetic DMARDs should be considered.
In addition to the latest treatment recommendations, the guidelines also contain a number of over-arching principles addressing patient care. The guidelines recommend that the primary healthcare provider to RA patients should be a rheumatologist. In addition, monitoring of disease activity should take place every one to three months dependent on the disease activity, with alterations to therapy considered if no improvement is observed by three months post-treatment, or if the target has not been reached by six months. Any initiation and adjustments of therapy should be made as a shared decision between patient and clinician, with factors including disease activity, progression of structural damage, co-morbidities and safety issues taken into account.
* These recommendations were developed by the EULAR Task Force on April 9, 2013; the exact wording is subject to change during the manuscript development process. The Task Force included Prof. Smolen, the chair; Dr.Landewé, the epidemiologist; rheumatologists from across Europe; patients; a health economist; and an infectious disease expert. The recommendations were based on three systematic literature reviews: one on synthetic DMARDs, one on biologic DMARD and one on safety issues related to treatment.
1. EULAR 2013 Rheumatoid Arthritis Management Recommendations, EULAR Data on File, 2013.
2. Chronic diseases and Health Promotion: Chronic Rheumatic Conditions, World Health Organisation. Available from: http://www.who.int/chp/topics/rheumatic/en/. Last accessed: May 2013
3. Michaud K, Wolfe F. Comorbidities in rheumatoid arthritis. Best Practice & Research Clinical Rheumatology. 2007; 21(5):885-906