New 2022 EULAR Recommendations for the Management of Rheumatoid Arthritis Save

The updated 2022 EULAR recommendations for the management of rheumatoid arthritis (RA) were initially presented by Dr. Josef Smolen at EULAR 2022, and are now in press delineating the most recent developments and perspectives in RA treatment.

Devised, reviewed and updated by an international task force who reviewed the medical literature and updates its consensus recommendations that were last published in 2019. The task force consisted of the steering group of 15 individuals and an additional 33 experts from multiple countries.

The new guidance has 5 overarching principles and 11 recommendations concerning use of conventional synthetic (cs) DMARDs (methotrexate (MTX), leflunomide, sulfasalazine); GCs; biological (b) DMARDs (tumour necrosis factor inhibitors (adalimumab, certolizumab pegol, etanercept, golimumab, infliximab including biosimilars), abatacept, rituximab, tocilizumab, sarilumab and Janus kinase inhibitors (tofacitinib, baricitinib, filgotinib, upadacitinib).

Specifically there is guidance on monotherapy, combination therapy, treat-to-target and tapering strategies, along with a safety focus on major cardiovascular events (MACEs) and malignancies.

MTX plus GCs is recommended and if there is an insufficient response within 3–6 months, treatment should guided by stratification according to risk factors. Importantly they note that with sustained remission, DMARDs may be tapered; but should not be stopped

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, safety issues and other patient factors, such as comorbidities and progression of structural damage. 
• Rheumatologists are the specialists who should primarily care for patients with RA. 
• Patients require access to multiple drugs with different modes of action to address the heterogeneity of RA; they may require multiple successive therapies throughout life. 
• RA incurs high individual, medical and societal costs, all of which should be considered in its management by the treating rheumatologist. 

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 glucocorticoids should be considered when initiating or changing csDMARDs, in different dose regimens and routes of administration, but should be tapered and discontinued 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, a bDMARD should be added; JAK-inhibitors may be considered, but pertinent risk factors must be taken into account.

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 or IL-6 receptor inhibitor therapy has failed, patients may receive an agent with another mode of action or a second TNF-/ IL-6R-inhibitor

11. After glucocorticoids have been discontinued and a patient is in sustained remission, dose reduction of DMARDs (bDMARDs/tsDMARDs* and/or csDMARDs) may be considered.

    *The following risk factors for cardiovascular events and malignancies must be considered when intending to prescribe a JAK-inhibitor: Age over 65 years, history of current or past smoking, other cardiovascular risk factors (such as diabetes, obesity, hypertension), other risk factors for malignancy (current or previous history of malignancy other than successfully treated non-melanoma skin cancer), risk factors for thromboembolic events (history of myocardial infarction or heart failure, cancer, inherited blood clotting disorders or a history of blood clots, as well as patients taking combined hormonal contraceptives or hormone replacement therapy, undergoing major surgery or immobile).

    Abbreviations: bDMARDs, biological disease-modifying antirheumatic drug; cs/tsDMARDs, conventional synthetic/targeted synthetic disease-modifying antirheumatic drug; JAK, Janus kinase; LoA, level of agreement; LoE, level of evidence; MTX, methotrexate; RA, rheumatoid arthritis; SoR, strength of recommendation.