Updated EULAR RA Treatment Recommendations Address Patient Concerns, Recent Developments

Since the European League Against Rheumatism’s (EULAR) initial recommendations in 2010 for how to manage rheumatoid arthritis (RA) with disease-modifying antirheumatic drugs (DMARDs), progress in the field necessitated 2 updates in 2013 and 2016. A third update was just released in the Annals of Rheumatic Diseases.

With clinical remission the main goal of RA treatment, using DMARDs enables symptom relief; improves physical function, quality of life, and social/work capacity; and inhibits structural damage to cartilage and bone.

This most recent update comprises 5 principles and 12 recommendations on the use of DMARDs—conventional synthetic (cs; methotrexate, leflunomide, sulfasalazine), biological (b; tumour necrosis factor [TNF] inhibitors [adalimumab, certolizumab pegol, etanercept, golimumab, infliximab], abatacept, rituximab, tocilizumab, sarilumab), biosimilar, and targeted synthetic (ts; Janus kinase inhibitors tofacitinib, baricitinib, filgotinib, upadacitinib)—and glucocorticoids to treat patients with RA. Included is guidance on mono- and combination therapies, treatment strategies, and tapering treatment. Altogether, this update considers patient benefits, safety, preferences, and costs related to RA treatment.

The 5 principles build on the previous updates, but they are not based on “specific scientific evidence.” Instead, they are overarching and address treating patients with RA:

1. Treatment should aim to provide the best care that is based on shared decision-making between patient and rheumatologist.
2. Treatment decisions should be based on disease activity, safety issues, and other patient factors (eg, comorbidities, disease progress, etc).
3. Rheumatologists should be the primary treating specialist for patients with RA.
4. Patients’ require and need access to different RA drugs throughout their lives, because the disease is heterogenous and may require a switch to a drug with a different mode of action.
5. Treating rheumatologists should consider the economic burden patients face when making therapeutic decisions.

The 12 recommendations also incorporate information from the previous updates. However, unlike the principles, they should be followed in this order:

1. Start DMARD therapy immediately following an RA diagnosis.
2. Make sustained remission or low disease activity the goal of treatment.
3. Monitor treatment on a regular basis and adjust as needed.
4. Incorporate methotrexate in a patient’s initial treatment; it also remains effective in combination with csDMARDs, bDMARDs, and tsDMARDs.
5. Consider leflunomide or sulfasalazine for initial treatment if methotrexate is contraindicated or a patient exhibits intolerance to it.
6. Consider short-term glucocorticoids if initiating/changing csDMARDS, but taper as soon as possible.
7. Switch to another csDMARD if the treatment goal is not reached with the first csDMARD.
8. Add a bDMARD or tsDMARD to csDMARD therapy if treatment goal is not reached and the patient has a poor prognosis.
9. Replace csDMARDs with interleukin-6 inhibitors or tsDMARDs when patients cannot use the former.
10. Incorporate one bDMARD/tsDMARD for another if treatment fails with the initial choice, but for TNF inhibitors that fail, there is a choice to introduce another agent or TNF inhibitor into the treatment regimen.
11. Scale back on bDMARDs or tsDMARDs in cases of persistent remission, after having already tapered glucocorticoids and when combination treatment includes a csDMARD.
12. Weight the decision to taper csDMARDs in cases of persistent remission.

These updated guidelines come on the heels of several new drug approvals in Europe after the 2016 update, and several of the principles and recommendations remain unchanged. However, the authors expect them to be revised again, and soon, so that patients can continue to receive optimal treatment from their treating rheumatologists and other stakeholders remain updated on progress in the field.

“We have reached a steady state of the evidence base for patients with established RA, although still some needs remain unmet, including the need to cure the disease. With the current rate of evidence development, we expect an update of the recommendations to be necessary in about 3-4 years,” they concluded.

Reference

Smolen JS, Landewé, RB, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2019 update [published online January 22, 2020]. Ann Rheum Dis. doi: 10.1136/annrheumdis-2019-216655.