2016 EULAR Guidelines on RA Management Save

The management of rheumatoid arthritis (RA) has evolved significantly with time.  Nevertheless, there are still some uncertainties - such as when, what and which biologic or novel therapy should be used.

A large international Task Force was established by EULAR to develop evidence based decisions from 3 systematic literature reviews. As such this panel has published 4 overarching principles and 12 recommendations. These recommendations address the use of conventional synthetic (cs) disease-modifying antirheumatic drugs (DMARDs) as well as biologic DMARDs (bDMARDs).  These guidelines are updated from that published in 2013.

Overarching Principles

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

EULAR recommendations

1. Therapy with 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 1–3 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. MTX should be part of the first treatment strategy.
5. In patients with a contraindication to MTX (or early intolerance), leflunomide or sulfasalazine should be considered as part of the (first) treatment strategy. 
6. Short-term GC should be considered when initiating or changing 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 bDMARD* or a 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, IL-6 pathway inhibitors and tsDMARDs may have some advantages compared with other bDMARDs
10.  If a bDMARD or tsDMARD has failed, treatment with another bDMARD or a 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 GC, 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. 

Abbreviations:   bDMARD, biological DMARD; bsDMARD, biosimilar DMARDs; csDMARDs, conventional synthetic DMARDs; DMARDs, disease-modifying antirheumatic drugs; EMA, European Medicines Agency; FDA, Food and Drug Administration; IL, interleukin; MTX, methotrexate; RF, rheumatoid factor; TNF, tumour necrosis factor; tsDMARDs, targeted synthetic DMARDs.