By Dr Irwin Lim, Rheumatologist
An international task force, comprising of prominent rheumatologists, a health economist, an infectious disease specialist, and patient representatives, recently provided updated recommendations for the management of Rheumatoid Arthritis (RA) using disease-modifying medications (DMARDs), both conventional synthetic DMARDs as well as the newer biological DMARDs.
For the full text, please visit this link.
These recommendations are based on the available scientific evidence as well as the opinions of these experts, and I suppose they provide a framework to help inform rheumatologists and their patients.
I thought you'd find it useful if I "translated" the 14 recommendations to more everyday-speak:
- Once a diagnosis of RA is made, treatment with DMARDs should start. This focuses on the importance of diagnosing RA early and treating it appropriately as soon as possible.
- The aim (or target) of treatment is to reach a state of remission or at least, low disease activity, in all patients. The lower the activity of this disease, the better the long term outcomes, and it therefore, makes sense to aim to control the disease very well.
- When the disease is active (poorly controlled), patients should be monitored more frequently (every 1-3 months). This monitoring allows for changes of treatment as we aim to achieve better disease control. It of course also allows vigilant monitoring and avoidance of any side effects.
- Methotrexate should be part of the initial treatment for patients with active disease. Methotrexate is an effective medication as monotherapy or in combination with other synthetic or biological DMARDs, and it continues to serve an the anchor drug in RA.
- In cases where Methotrexate is contraindicated (or if not tolerated), Leflunomide or Sulfasalazine should be considered as part of the initial treatment strategy.
- In patients who have never been treated with DMARDs, conventional DMARD monotherapy (eg Methotrexate) or combination DMARD therapy (eg triple therapy) should be used.
- Low dose glucocorticoids (eg Prednisone) should be considered as part of the initial treatment in combination with one or more DMARDs. Glucocorticoids or steroids provide symptom relief and improve function. Lower doses are recommended (eg 7.5mg daily Prednisone equivalent or less) with the dose tapered as quickly as clinically appropriate.
- If the treatment target is not reached using the initial treatment strategy, change to another DMARD strategy should be considered.
- If patients with RA are not responding well enough to Methotrexate and/or other conventional synthetic DMARD strategies, biologic DMARDS should be commenced with Methotrexate (includes TNF inhibitors, Abatacept, Tocilizumab, Rituximab).
- If the first biologic DMARD has failed to achieve the target, patients should be treated with another biologic DMARD. If a first TNF inhibitor therapy has failed, patients may trial another TNF inhibitor or trial a biologic DMARD with a different mode of action.
- Tofacitinib may be considered after biological DMARD treatment has failed. Tofacitinib, is a new agent, a JAK inhibitor. It is not a biologic DMARD and is a synthetic chemical molecule that is more targeted in how it works than the conventional synthetic DMARDS (eg Methotrexate and Sulfasalazine). While it seems an effective agent, there is much less data on its long term safety at this point in time.
- If a patient is in remission for some time, and not requiring glucocorticoids/steroids to achieve this, one can consider tapering the biologic DMARDs, especially if the patient is also on a conventional synthetic DMARD.
- In patients who have sustained, long term remission, without requiring the use of glucocorticoids/steroids, reduction in dose of the conventional synthetic DMARD could be considered.
- When treatment is changed or adjusted, factors other than disease activity need to be weighed up. These include worsening structural damage as seen on imaging, other medical issues the patient may have or safety concerns.
The full text contains much greater discussion and many useful references, but it is likely to prove confusing and quite "heavy" for the non-medically trained. I hope my much briefer summary is helpful.Dr Irwin Lim is a rheumatologist and a director of BJC Health. You should follow him on twitter here. Arthritis requires an integrated approach. We call this, Connected Care. Contact us.