EULAR has updated its recommendations for the pharmacological management of rheumatoid arthritis (RA) with DMARDs to reflect developments since the previous update in 2016, including the approval of several new drugs and the accumulation of long-term safety and efficacy data. Major changes had not been anticipated, and indeed most of the recommendations remain unchanged. “If one looks at the EULAR recommendations from their first presentation exactly one decade ago and throughout the updates in 2013 and 2016, one can see that this combination of evidence and expert opinion has stood the test of time,” remarks lead author Josef Smolen.

In the latest update, which is based on systematic literature reviews and the opinions of experts from around the world, the target of treatment remains as sustained remission (according to the ACR–EULAR definition) or low disease activity. This goal is considered achievable for most patients with RA, but might require cycling through multiple different drugs. Moreover, although guidance is provided on the tapering of medication for patients who achieve sustained remission, it is also recognized that many patients will require lifelong treatment.

The recommendations provide a sequential treatment strategy, as summarized in an algorithm that provides a general overview. “The algorithm divides the therapeutic cascade into three phases: initial approach, failure of methotrexate plus glucocorticoids, and failure of a first biologic or targeted synthetic DMARD,” notes Smolen.

The initial DMARD strategy remains methotrexate plus glucocorticoids. If the treatment target is not achieved and unfavourable prognostic markers are present, a biologic or targeted synthetic DMARD should be added; in a change from the previous update (which favoured biologic over targeted synthetic DMARDs), preference is not given to either type of DMARD, in light of evidence of the efficacy and safety of JAK inhibitors.

The recommendations provide a sequential treatment strategy

The task force behind the recommendations also provided an updated research agenda to highlight important issues to address in future updates, including the safety and efficacy of various sequences and combinations of drugs, the need for biomarkers to stratify patients and predict therapeutic response, and the reasons for secondary loss of efficacy.