Management of rheumatoid arthritis: 2019 updated consensus recommendations from the Hong Kong Society of Rheumatology

Abstract

The expanding range of treatment options for rheumatoid arthritis (RA), from conventional synthetic disease-modifying antirheumatic drugs (DMARDs) to biological DMARDs (bDMARDs), biosimilar bDMARDs, and targeted synthetic DMARDs, has improved patient outcomes but increased the complexity of treatment decisions. These updated consensus recommendations from the Hong Kong Society of Rheumatology provide guidance on the management of RA, with a focus on how to integrate newly available DMARDs into clinical practice. The recommendations were developed based on evidence from the literature along with local expert opinion. Early diagnosis of RA and prompt initiation of effective therapy remain crucial and we suggest a treat-to-target approach to guide optimal sequencing of DMARDs in RA patients to achieve tight disease control. Newly available DMARDs are incorporated in the treatment algorithm, resulting in a greater range of second-line treatment options. In the event of treatment failure or intolerance, switching to another DMARD with a similar or different mode of action may be considered. Given the variety of available treatments and the heterogeneity of patients with RA, treatment decisions should be tailored to the individual patient taking into consideration prognostic factors, medical comorbidities, drug safety, cost of treatment, and patient preference.

Diagnostic Challenges and Management Update in Rheumatoid Arthritis

“…Patients are recommended to use appropriate skin protection. TNFi does not increase the risk of congenital malformation and is classified as pregnancy category B (no documented human toxicity) [110,113]. However, due to the intense placental transfer of Ig in the third trimester, TNFi may increase the risk of neonatal bacterial and fungal infections.…”

“…However, due to the intense placental transfer of Ig in the third trimester, TNFi may increase the risk of neonatal bacterial and fungal infections. The lowest risk appears in etanercept and certolizumab, which are preferred for administration [113].…”

“…Treatment should be discontinued if there is no response after 12 weeks of treatment. Due to its reduced placental transfer, certolizumab is one of the safest biologic agents for use in pregnancy and can be given during all trimesters [107,109,113].…”

“…Supplementary precautions should be taken in pregnancy and administration of rituximab, tocilizumab, and abatacept, due to their limited safety documentation when compared with TNFi [113].…”

The 2019 Updated Hong Kong Society of Rheumatology Consensus Statements for the Management of Rheumatoid Arthritis

“…We are certain that these updated recommendations are useful to guide local rheumatologists in the management of RA. Readers should refer to the full paper of this updated consensus which will be posted up in due course on the HKSR website [8].…”