ObjectivesTo provide an update of the EULAR rheumatoid arthritis (RA) management recommendations
addressing the most recent developments in the field. MethodsAn international task
force was formed and solicited three systematic literature research activities on
safety and efficacy of disease-modifying antirheumatic drugs (DMARDs) and glucocorticoids
(GCs). The new evidence was discussed in light of the last update from 2019. A predefined
voting process was applied to each overarching principle and recommendation. Levels
of evidence and strengths of recommendation were assigned to and participants finally
voted on the level of agreement with each item. ResultsThe task force agreed on 5
overarching principles and 11 recommendations concerning use of conventional synthetic
(cs) DMARDs (methotrexate (MTX), leflunomide, sulfasalazine); GCs; biological (b)
DMARDs (tumour necrosis factor inhibitors (adalimumab, certolizumab pegol, etanercept,
golimumab, infliximab including biosimilars), abatacept, rituximab, tocilizumab, sarilumab
and targeted synthetic (ts) DMARDs, namely the Janus kinase inhibitors tofacitinib,
baricitinib, filgotinib, upadacitinib. Guidance on monotherapy, combination therapy,
treatment strategies (treat-to-target) and tapering in sustained clinical remission
is provided. Safety aspects, including risk of major cardiovascular events (MACEs)
and malignancies, costs and sequencing of b/tsDMARDs were all considered. Initially,
MTX plus GCs is recommended and on insufficient response to this therapy within 3-6
months, treatment should be based on stratification according to risk factors; With
poor prognostic factors (presence of autoantibodies, high disease activity, early
erosions or failure of two csDMARDs), any bDMARD should be added to the csDMARD; after
careful consideration of risks of MACEs, malignancies and/or thromboembolic events
tsDMARDs may also be considered in this phase. If the first bDMARD (or tsDMARD) fails,
any other bDMARD (from another or the same class) or tsDMARD (considering risks) is
recommended. With sustained remission, DMARDs may be tapered but should not be stopped.
Levels of evidence and levels of agreement were high for most recommendations. ConclusionsThese
updated EULAR recommendations provide consensus on RA management including safety,
effectiveness and cost.
