Updated EULAR Recommendations For RA Management - Dr. Kathryn Dao Save

This is Doctor. Catherine Dow reporting on the last day of EULAR. It's been a really good meeting. And one of the highlights of the finale here is that Professor Joseph Smolin presented the 2019 updated EULAR guidelines on the management of rheumatoid arthritis. They recently published these guidelines just a month or so ago, and the question you probably are asking, because this is the question I ask, is why did they update their guidelines when their last guidelines was from 2016?

We still use at ACR the 2015 guidelines, but they actually have quite a few good reasons. And first of all is that there's been like an evolving data of so much, information for the treatment strategies, novel therapies. There's also comparative effectiveness studies as well as, incorporating the patient's voice on the cost of the medications as well as the safety aspects. So I wanted to go over the highlights of the guidance documents. There's five overarching principles and 12 recommendations.

So basically the overarching principles include that treatment should be aimed at the best care of the patient and it's a shared decision making process between the patient and the rheumatologist. In addition, treatment is based on the disease activity, safety, and patient factors such as the patient's comorbidities as well as progression of structural damage. Third, rheumatologists should be the primary care provider for the rheumatoid arthritis in the patient. And fourth, patients oftentimes may have multiple successive therapies throughout their lives, so they have to be able to access drugs with different mechanisms of actions. And fifth, RA itself incurs very high individual, medical, and societal costs, and that should be considered in the management of rheumatoid arthritis.

So what about the recommendations itself? So the first recommendation is that once rheumatoid arthritis is diagnosed, therapy with DMARR should be initiated. The second thing that EULAR recommends is that you need to treat to target. Identify your target as low disease activity or remission, and you need to monitor the activity of the disease frequently every one to three months because if patients have been on a disease modifying drug and do not have any improvement at three months, you really got to consider switching therapies. Or if the target, which is low disease activity or remission, is not achieved by six months, you should go ahead and consider doing something more for the patient.

Methotrexate should be the part, should be part of the first treatment strategy, but in patients who have contraindications to methotrexate, could use leflutamide or sulfasalazine. Now, they did not mention anything about hydroxychloroquine and I would say that they do not recommend hydroxychloroquine monotherapy as a first line treatment. You could use it in combination, but not just first line monotherapy by itself. In addition, sometimes patients may require a short term glucocorticoid bridge, and you can use this when initiating a DMARD or if you're changing, your DMARDs to something else, and you just need that bridge to help patients during their flares. And if the target is not achieved with the first conventional synthetic DMARDs, then you have to consider other conventional synthetic DMARDs in the absence of poor prognostic factors.

And so what are all the poor prognostic That includes seropositivity, so positive RF, positive CCP, evidence of erosions, patients who have failed multiple therapies. So those are patients with poor prognoses. And then if the target is not achieved with the first DMARD and the patient has poor prognostic factors, then you really want to go ahead and think about adding a biologic DMARD or a targeted synthetic DMARDs. So these includes the JAK inhibitors. So if a biologic or a JAK inhibitor fails, then you want to think about switching to another biologic.

So that could be another TNF inhibitor, or it could be another biologic with a different mechanism of action. EULI pretty much leaves it to the clinician to decide, so it's a shared decision making between the clinician as well as the patient. Now, if a patient is in persistent remission after tapering steroids, then they do recommend that you could consider tapering the biologic or the JAK inhibitor, especially if treatment has been combined with the regular conventional synthetic DMARN. And then if a patient's been in persistent remission and they're not on a biologic or a JAK inhibitor, then at that point you could consider tapering the disease modifying antirheumatic drug. So how do these ULAD recommendations differ from the ACR recommendations?

In a couple of aspects. So the ULAD recommendations had kind of divided the patients up as to biologic and synthetic DMARD naive, then you have the DMARD failure, and that's the conventional synthetic DMARD failure, and then you have the biologic targeted therapy failures. So, And then they really, like, divided up how to manage these patients. And then ACR, what they did was they said, You really don't want to taper off any kind of, DMARDs, even if a patient is in remission for a while. So, and then, ACR also prefers a TNF inhibitor as the first line biologic before you go on to a biologic of a different mechanism of action, unless there's a contraindication.

So I had a great time at ULAR and I hope that you've enjoyed following my tweets and as well as my blog and my videos. So have a great day.