JAMA Review of DMARD Use in Rheumatoid Arthritis Save

JAMA has reviewed the "2022 EULAR Recommendations for the Management of Rheumatoid Arthritis With Synthetic and Biological Disease-Modifying Antirheumatic Drugs". 

Highlighted recommendations include:

• Conventional synthetic disease-modifying antirheumatic drugs (csDMARDs), such as methotrexate, should be started as soon as diagnosis of RA is made (level of evidence [LoE]: 1a; strength of recommendation [SoR]: A)

• Monitor every 1 to 3 months during active disease. Adjust therapy if no improvement occurs by 3 months, if no remission occurs in those with early disease, or if low disease activity is not achieved by 6 months in those with long-standing disease (LoE: 2b; SoR: B)

• Methotrexate should be part of the first treatment strategy unless contraindicated (LoE: 1a; SoR: A)

• Short-term glucocorticoids should be considered when initiating or changing csDMARDs but tapered and discontinued as rapidly as clinically feasible (LoE: 1a; SoR: A)

• If treatment targets are not achieved with the first csDMARD, when poor prognostic factors are present, a biologic DMARD (such as a tumor necrosis factor [TNF] inhibitor) should be added. Janus kinase (JAK) inhibitors may be considered, but pertinent risk factors must be taken into account (LoE for efficacy: 1a; LoE for safety: 1b; SoR for efficacy: A; SoR for safety: B)

Important points to consider

• Earlier use of DMARDs is critical. Remission at 12 months is signifiantly greater (63.3%  vs 27.5%) if given to those with disease <3 months vs. those w/ disease ≥3 months (OR, 2.4; 95% CI, 1.1-5.6).
• Methotrexate can cause cytopenia, nephrotoxicity, gastrointestinal effects (nausea, vomiting, oral ulcers), fatty liver and fibrosis, and inflammatory and fibrotic lung disease
• EULAR differs from the 2021 ACR RA guidelines by having greater support for judicious use of steroids
• The role of glucocorticoids in RA needs further assessment for starting and stopping therapy, optimal doses and use with comorbid conditions such as diabetes or osteoporosis.