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JAMA Review of DMARD Use in Rheumatoid Arthritis

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.

Join The Discussion

Saurav Suman

| Mar 13, 2024 1:51 pm

methotrexate causes nephrotoxocity?

and causes fibrotic lung disease?

No. MTX does not cause nephrotoxicity. BUT!!! CKD causes MTX toxicity!

MTX does not cause or worsen RA-ILD

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The author has no conflicts of interest to disclose related to this subject