EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2019 update

Publication

EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2019 update

Journal Paper/Review - Jan 22, 2020

van der Heijde Désirée, Mariette Xavier, Li Zhanguo, Koloumas Marios, Huizinga Tom W J, Hetland Merete Lund, Gottenberg Jacques-Eric, Gossec Laure, Finckh Axel, Emery Paul, Müller-Ladner Ulf, Mysler Eduardo F, da Silva Jose A P, Westhovens René, Voshaar Marieke, Takeuchi Tsutomu, Strangfeld Anja, Saag Kenneth G, Ruyssen-Witrand Adeline, Rubbert-Roth Andrea, Pope Janet E, Poór Gyula, van Eijk-Hustings Yvonne, Edwards Christopher John, Cutolo Maurizio, de Wit Maarten, van Vollenhoven Ronald F, Sepriano Alexandre, McInnes Iain B, Kerschbaumer Andreas, Dougados Maxime, Burmester Gerd R, Bijlsma Johannes W J, Landewé Robert B M, Aletaha Daniel, Aringer Martin, Askling John, Codreanu Catalin, De Cock Diederik, Cardiel Mario Humberto, Caporali Roberto, Buttgereit Frank, Buch Maya H, den Broeder Alfons A, Boers Maarten, Balsa Alejandro, Smolen Josef S

Citation

van der Heijde D, Mariette X, Li Z, Koloumas M, Huizinga T, Hetland M, Gottenberg J, Gossec L, Finckh A, Emery P, Müller-Ladner U, Mysler E, da Silva J, Westhovens R, Voshaar M, Takeuchi T, Strangfeld A, Saag K, Ruyssen-Witrand A, Rubbert-Roth A, Pope J, Poór G, van Eijk-Hustings Y, Edwards C, Cutolo M, de Wit M, van Vollenhoven R, Sepriano A, McInnes I, Kerschbaumer A, Dougados M, Burmester G, Bijlsma J, Landewé R, Aletaha D, Aringer M, Askling J, Codreanu C, De Cock D, Cardiel M, Caporali R, Buttgereit F, Buch M, den Broeder A, Boers M, Balsa A, Smolen J. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2019 update. Ann Rheum Dis 2020; 79:685-699.

Type

Journal Paper/Review (English)

Journal

Ann Rheum Dis 2020; 79

Publication Date

Jan 22, 2020

Issn Electronic

1468-2060

Pages

685-699

Brief description/objective

OBJECTIVES
To provide an update of the European League Against Rheumatism (EULAR) rheumatoid arthritis (RA) management recommendations to account for the most recent developments in the field.

METHODS
An international task force considered new evidence supporting or contradicting previous recommendations and novel therapies and strategic insights based on two systematic literature searches on efficacy and safety of disease-modifying antirheumatic drugs (DMARDs) since the last update (2016) until 2019. A predefined voting process was applied, current levels of evidence and strengths of recommendation were assigned and participants ultimately voted independently on their level of agreement with each of the items.

RESULTS
The task force agreed on 5 overarching principles and 12 recommendations concerning use of conventional synthetic (cs) DMARDs (methotrexate (MTX), leflunomide, sulfasalazine); glucocorticoids (GCs); biological (b) DMARDs (tumour necrosis factor inhibitors (adalimumab, certolizumab pegol, etanercept, golimumab, infliximab), abatacept, rituximab, tocilizumab, sarilumab and biosimilar (bs) DMARDs) and targeted synthetic (ts) DMARDs (the Janus kinase (JAK) inhibitors tofacitinib, baricitinib, filgotinib, upadacitinib). Guidance on monotherapy, combination therapy, treatment strategies (treat-to-target) and tapering on sustained clinical remission is provided. Cost and sequencing of b/tsDMARDs are addressed. Initially, MTX plus GCs and upon insufficient response to this therapy within 3 to 6 months, stratification according to risk factors is recommended. With poor prognostic factors (presence of autoantibodies, high disease activity, early erosions or failure of two csDMARDs), any bDMARD or JAK inhibitor should be added to the csDMARD. If this fails, any other bDMARD (from another or the same class) or tsDMARD is recommended. On sustained remission, DMARDs may be tapered, but not be stopped. Levels of evidence and levels of agreement were mostly high.

CONCLUSIONS
These updated EULAR recommendations provide consensus on the management of RA with respect to benefit, safety, preferences and cost.