EULAR Updates Rheumatoid Arthritis Treatment Guidelines for DMARDs

Members of a steering committee and task force have updated the European League Against Rheumatism (EULAR) recommendations for rheumatoid arthritis management to include new guidelines on starting effective therapy in patients early with a goal of low disease activity or stringent remission across 3 phases of treatment, according to recently published guidelines in the Annals of Rheumatic Diseases.

Josef S. Smolen, MD, from the Division of Rheumatology, Department of Medicine at the Medical University of Vienna in Austria, and colleagues formed a steering committee comprising 7 rheumatologists, 1 patient representative, and 3 fellows and a task force of 50 individuals, which consisted of members from the committee as well as 3 patients, 2 health professionals, and 2 delegates of the EULAR young rheumatologists’ network, Emerging Eular NETwork (EMEUNET), to review EULAR recommendations for RA management from 2013. The groups performed a systematic literature review of the latest information, strategies, trials of new agents, and the latest insights since the 2013 recommendations were published.

The task force endorsed 4 overarching principles for the recommendations:

1. Treatment of patients with RA should aim for the best care and must be based on a shared decision between the patient and the rheumatologist.
2. Treatment decisions are based on disease activity and other patient factors, such as progression of structural damage, comorbidities, and safety issues.
3. RA incurs high individual, medical, and societal costs, all of which should be considered in its management by the treating rheumatologist.
4. Rheumatologists are the specialists who should primarily care for patients with RA.

The researchers noted the second principle on treatment decisions was initially a recommendation in the 2013 guidelines but became an overarching principle in the new guidelines because it represented a “central and self-evident rule to any therapeutic approach that it should constitute an overarching principle rather than a recommendation.”

Additionally, the EULAR steering committee and task force released 12 recommendations based on their literature review, which was a consolidation of 14 recommendations in the 2013 guidelines. The recommendations are not ranked in order but are listed based on the need for initial effective therapy early and to set a treatment target.

“With these prerequisites in mind, different drugs or combinations of agents are recommended in the course of the therapeutic procedures, with suggested sequential increments, taking prognostic factors and all approved agents into account,” Dr Smolen and colleagues wrote. “They also mention some agents of potential future interest, even though not yet approved by international regulatory authorities.”

The EULAR steering committee and task force made the following recommendations for RA management:

1. Therapy with disease-modifying antirheumatic drugs (DMARDs) should be started as soon as the diagnosis of RA is made.
2. Treatment should be aimed at reaching a target of sustained remission or low disease activity in every patient.
3. Monitoring should be frequent in active disease (every 1 to 3 months); if there is no improvement by at most 3 months after the start of treatment or the target has not been reached by 6 months, therapy should be adjusted.
4. Methotrexate should be part of the first treatment strategy.
5. In patients with a contraindication to methotrexate (or early intolerance), leflunomide or sulfasalazine should be considered as part of the (first) treatment strategy.
6. Short-term glucocorticoids should be considered when initiating or changing conventional synthetic DMARDs (csDMARDS) in different dose regimens and routes of administration but should be tapered as rapidly as clinically feasible.
7. If the treatment target is not achieved with the first csDMARD strategy, in the absence of poor prognostic factors, other csDMARDs should be considered.
8. If the treatment target is not achieved with the first csDMARD strategy, when poor prognostic factors are present, addition of a biological DMARD (bDMARD) or a targeted synthetic DMARD (tsDMARD) should be considered; current practice would be to start a bDMARD.
9. bDMARDs and tsDMARDs should be combined with a csDMARD; in patients who cannot use csDMARDs as comedication, interleukin-6 pathway inhibitors, and tsDMARDs may have some advantages compared with other bDMARDs.
10. If treatment with a bDMARD or tsDMARD has failed, treatment with another bDMARD or tsDMARD should be considered; if one TNF-inhibitor therapy has failed, patients may receive another TNF-inhibitor or an agent with another mode of action.
11. If a patient is in persistent remission after having tapered glucocorticoids, one can consider tapering bDMARDs, especially if this treatment is combined with a csDMARD.
12. If a patient is in persistent remission, tapering the csDMARD could be considered.

Summary and Clinical Applicability

“The 2016 update of the EULAR recommendations is based on the most recent evidence in the area of RA management and on discussions by a large and broadly international Task Force. The recommendations synthesize the current thinking on approaching RA treatment in a set of overarching principles and recommendations,” Dr Smolen and colleagues wrote in their study.

“These have been informed by [systematic literature reviews] on the efficacy and safety of the drugs. The Task Force is convinced that adhering to these recommendations, including shared decision making, defining the treatment target, assessing disease activity regularly with appropriate instruments and applying the sequence of drugs as proposed and in a treat-to-target strategy, will maximize the overall outcome in a vast majority of patients with RA.”

Disclosures

The researchers report various financial disclosures, available as an online supplement.

Reference

Smolen JS, Landewé R, Bijlsma J, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2016 update [published online March 6, 2017]. Ann Rheum Dis. 2017; doi: 10.1136/annrheumdis-2016-210715

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