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EULAR Issues Updated Arthritis Guidelines

Recommendations address use of synthetic and biologic DMARDs (July 3)

The European League Against Rheumatism (EULAR) has released updated recommendations for the management of rheumatoid arthritis (RA). According to this latest guidance, treatment with disease-modifying antirheumatic 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 that 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 6 months, but should be tapered as soon as clinically feasible.

“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% to 50% of patients with early RA, who will achieve the treatment target with such initial therapy,” said Professor Josef Smolen.

However, in patients who fail to respond to this treatment within 6 months, and when poor prognostic factors are present, biological DMARDs (tumor necrosis factor [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. Similarly, 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.

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 updated 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 1 to 3 months, depending on the disease activity. Alterations to therapy should be considered if no improvement is observed by 3 months post-treatment, or if the target has not been reached by 6 months. Any initiation and adjustments of therapy should be made as a shared decision between the patient and the clinician, taking into account such factors as disease activity, the progression of structural damage, co-morbidities, and safety issues.

Source: EULAR; July 3, 2013.

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