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

Journal Paper/Review - Jan 22, 2020

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Citation
Smolen J, Landewé R, Bijlsma J, Burmester G, Dougados M, Kerschbaumer A, McInnes I, Sepriano A, van Vollenhoven R, de Wit M, Aletaha D, Aringer M, Askling J, Balsa A, Boers M, den Broeder A, Buch M, Buttgereit F, Caporali R, Cardiel M, De Cock D, Codreanu C, Cutolo M, Edwards C, van Eijk-Hustings Y, Emery P, Finckh A, Gossec L, Gottenberg J, Hetland M, Huizinga T, Koloumas M, Li Z, Mariette X, Müller-Ladner U, Mysler E, da Silva J, Poór G, Pope J, Rubbert-Roth A, Ruyssen-Witrand A, Saag K, Strangfeld A, Takeuchi T, Voshaar M, Westhovens R, van der Heijde D. 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.
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Journal Paper/Review (English)
Journal
Ann Rheum Dis 2020; 79
Publication Date
Jan 22, 2020
Issn Print
Issn Electronic
1468-2060
Pages
685-699
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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.