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

Abstract

ObjectivesTo 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.MethodsAn 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.ResultsThe 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.ConclusionsThese updated EULAR recommendations provide consensus on the management of RA with respect to benefit, safety, preferences and cost.

Translating IL-6 biology into effective treatments

“…In particular, a head-to-head, double-blind, double-dummy RCT found that, when used as monotherapy, tocilizumab was superior to the TNF inhibitor adalimumab in measures of disease activity and several other outcomes 46 . On the basis of these results, EULAR recommendations for the management of RA named IL-6 pathway inhibitors as one of the preferred treatment options for patients for whom methotrexate is inappropriate 60 . Interestingly, the clinical benefits of IL-6 inhibition might be attributable, in part, to the beneficial effects of IL-6 inhibition on bone and cartilage turnover, which are supported by data from prospective cohort studies showing that tocilizumab monotherapy achieves better repair of focal bone erosions than TNF inhibition in patients with RA [60][61][62][63][64][65][66][67][68][69][70] .…”

The anti-viral facet of anti-rheumatic drugs: Lessons from COVID-19

“…Glucocorticoids (GCs) are among the most frequently used agent in rheumatologic clinical practice. The GCs have proved to be effective in the management of a broad spectrum of diseases such as RA, systemic lupus erythematosus (SLE), vasculitis both representing the main treatment or a bridging/supporting therapy to the immunosuppressant [17][18][19][20].…”

COVID-19 infection and rheumatoid arthritis: Faraway, so close!

“…Another important determinant of infectious risk is the presence of comorbidities, which very often complicate the course of RA [34]. Diabetes mellitus, cardiovascular diseases, renal failure, interstitial lung disease, and chronic obstructive pulmonary disease (COPD) are all concomitant It has now been more than 70 years that corticosteroids (CS) are pivotal for RA management and their role as remission inducer and bridging therapy for the management of disease flare has recently been renewed by the latest update of EULAR recommendations for RA treatment [36].…”