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DMARDs: Practical Recommendations for Rheumatoid Arthritis Treatment

Recommendations on the Management of Rheumatoid Arthritis (RA) with DMARDs

A cure for rheumatoid arthritis is not yet possible, that’s fact. However, remission is within one’s reach today. 

RA treatment has undergone dramatic changes the last ten years.

Concerning this, an EULAR task force (EULAR is The European League Against Rheumatism) has recently developed and released new RA guidelines for the management of rheumatoid arthritis (RA), based on an systematic literature review.

In these brand new RA recommendations the dramatic developments in therapeutic options in recent years have been recognized as well as the difficulties this has created in defining simple treatment algorithms. The EULAR guidelines can be downloaded free from the EULAR journal Annals of the Rheumatic Diseases free of charge. 

So what’s the paper about? – The essentials in brief

The recommendations state three “overarching” principles: 

  • Rheumatoid arthritis should be managed primarily by rheumatologists.
  • Rheumatoid arthritis treatment should aim for “best care”. It should be based on shared decision-making between patient and rheumatologist – what comes under the heading of “compliance”.
  • Rheumatoid arthritis is expensive, in regards to medical costs and productivity costs, both of which should be considered by the treating rheumatologist. In weighing on the ideal treatment strategy the costs of RA treatment need to be balanced against the costs of having the disease, the expert committee stated.

A concise list of 15 recommendations (see below) set out the details of therapy. –  The first is: Treatment with synthetic disease-modifying antirheumatic drugs, DMARDs, should be commenced as soon as possible and as soon as the diagnosis is made. 

It is this DMARD treatment that has undergone dramatic changes the last ten years, opening up therapeutic dimensions unforeseen before, the authors state. For patients with active rheumatoid arthritis methotrexate  (MTX) should be the first choice, they say. 

Should be commenced as soon as possible: treatment with synthetic DMARDs.

Crucial point of the article and what gives hope both doctors and patients: Remission is possible nowadays, and remission or low disease activity should be targeted as soon as possible and in every patient. 

As long as that is not reached, according to the authors, treatment should be adjusted with frequent and strict monitoring every one to three months. By the way, my blog post 10 Clinical Facts About Rheumatoid Arthritis posted six weeks ago is along the same line. 

15 EULAR recommendations on DMARDs

Listed below you will find the 15 EULAR recommendations in brief (as also presented in the table 1 of the EULAR paper).  In the article, the recommendations are formulated in detail, so please look it up in the original, if needed.  

  1. Synthetic DMARDs early: Treatment with synthetic DMARDs should be started as soon as the diagnosis of rheumatoid arthritis is made.
  2. Treatment targeting remission or low disease: Treatment should be aimed at reaching a target of remission or low disease activity as soon as possible in every patient. As long as the target has not been reached, treatment should be adjusted by frequent (every 1 – 3 month) and strict monitoring.
  3. Methotrexate as initial choice: MTX should be part of the first treatment strategy in patients with active rheumatoid arthritis.
  4. Leflunomide, sulfasalazine or injectable gold: When MTX contraindications (or intolerance) are present, the following DMARDs should be considered as part of the (first) treatment strategy: leflunomide, sulfasalazine (SSZ) or injectable gold.
  5. Synthetic DMARD monotherapy or combination therapy: In DMARD naïve patients, irrespective of the addition of glucocorticoids (GCs), synthetic DMARD monotherapy rather than combination therapy of synthetic DMARDs may be applied.
  6. Glucocorticoids: Glucocorticoids (GCs) added at low to moderately high doses to synthetic DMARD monotherapy (or combinations of synthetic DMARDs) provide benefit as initial short-term treatment, but should be tapered as rapidly as clinically feasible.
  7. Treatment of a biological DMARD or switch to another synthetic DMARD:If the treatment target is not achieved with the first DMARD strategy, addition of a biological DMARD should be considered when poor prognosis factors are present. In the absence of poor prognostic factors, switching to another synthetic DMARD strategy should be considered.

    If treatment target is not achieved by the first DMARD, addition of a biological DMARD should be considered.

  8. Initiation of a TNF inhibitor: In patients responding insufficiently to MTX and/or other synthetic DMARDs with or without GCs, biological DMARDs should be started. Current practice would be to start a TNF inhibitor (adalimumab, certolizumab, etanercept, golimumab, infliximab) which should be combined with MTX.
  9. Abatacept, rituximab or tocilizumab: Patients with RA for whom a first TNF inhibitor has failed, should receive another tumor necrosis factor (TNF) inhibitor, abatacept, rituximab or tocilizumab.
  10. Azathioprine, cyclosporine A or cyclophosphamide: In cases of refractory severe rheumatoid arthritis or contraindications to biological agents or the previously mentioned synthetic DMARDs, the following synthetic DMARDs might be also considered, as monotherapy or in combination with some of the above: azothioprine, ciclosporin A (or exceptionally, cyclophosphamide)
  11. Intensive medications strategies: Intensive medication strategies should be considered in every patient, although patients with poor prognostic factors have more to gain.
  12. Tapering biological DMARDs: If a patient is in persistent remission, after having tapered glucocorticoids, one can consider tapering biological DMARDs, especially if this treatment is combined with synthetic DMARD.
  13. Tapering of synthetic DMARDs: In cases of sustained long-term remission, cautions titration of synthetic DMARD dose could be considered, as a shared decision between patient and doctor.
  14. Biological treatment in DMARD naïve patients: DMARD naïve patients with poor prognostic markers might be considered for combination therapy of MTX plus a biological agent.
  15. Adjustment of treatment:When adjusting treatment, factors apart from disease activity, such as progression of structural damage, comorbidities and safety concerns should be taken into account.

    As long as the target has not been reached, treatment should be adjusted by frequent and strict monitoring.

I hope you enjoyed reading this post! I am positive this information is also of interest to RA patients and their families, beyond rheumatologists. So I do really hope, they will gain knowledge of these recommendations, and that they will be able to discuss treatment strategies with their doctors. 



JS Smolen et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs. Ann Rheum Dis 2010;69:964-975 – doi:10.1136/ard.2009.126532 


Author of this article:  Tobias Stolzenberg 

all pictures are taken from stock.xchng: Tablets 3, Injection 1, Tablets 2, thumbs up!____________________________________________________

1 Comment

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  1. Pls tell more about injectible Gold in RA. I understand that gold is also used for combating RA in Homoeopathy and Ayurvedic treatement.

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