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Ann Rheum Dis. 2017 Jun;76(6):960-977. doi: 10.1136/annrheumdis-2016-210715. Epub 2017 Mar 6.

EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2016 update.

Author information

1
Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Austria.
2
2nd Department of Medicine, Hietzing Hospital, Vienna, Austria.
3
Amsterdam Rheumatology & Immunology Center, Amsterdam, The Netherlands.
4
Zuyderland Medical Center, Heerlen, The Netherlands.
5
Department of Rheumatology and Clinical Immunology, University Medical Center Utrecht, Utrecht, The Netherlands.
6
Department of Rheumatology and Clinical Immunology, Charité-University Medicine Berlin, Free University and Humboldt University Berlin, Berlin, Germany.
7
Rheumatology Department, Karolinska Institute, Stockholm, Sweden.
8
Rhumatologie B, Hopital Cochin, Paris, France.
9
NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust and Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK.
10
Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands.
11
Department of Psychology, Health and Technology, University of Twente, Enschede, The Netherlands.
12
Division of Rheumatology, Medizinische Klinik und Poliklinik III, Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.
13
Department of Epidemiology and Biostatistics, VU University Medical Center, Amsterdam, The Netherlands.
14
Birmingham NIHR Wellcome Trust Clinical Research Facility, Rheumatology Research Group, Institute of Inflammation and Ageing (IIA), University of Birmingham, Queen Elizabeth Hospital, Birmingham, UK.
15
Department of Rheumatology, Hospital for Special Surgery, Weill Cornell Medical College, New York, New York, USA.
16
Rebecca McDonald Center for Arthritis & Autoimmune Disease, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada.
17
Centro de Investigación Clínica de Morelia SC, Michoacán, México.
18
Rheumatology Department, Lapeyronie Hospital, Montpellier University, UMR 5535, Montpellier, France.
19
Research Laboratory and Division of Clinical Rheumatology, University of Genoa, Genoa, Italy.
20
Department of Patient & Care and Department of Rheumatology, University of Maastricht, Maastricht, The Netherlands.
21
Division of Rheumatology, University Hospitals of Geneva, Geneva, Switzerland.
22
Fundación Ramón Dominguez, Hospital Clinico Universitario, Santiago, Spain.
23
Department of Rheumatology, Sorbonne Universités, Pitié Salpêtrière Hospital, Paris, France.
24
Institut de Biologie Moléculaire et Cellulaire, Immunopathologie, et Chimie Thérapeutique, Strasbourg University Hospital and University of Strasbourg, CNRS, Strasbourg, France.
25
Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.
26
Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, University of Manchester, Manchester, UK.
27
V.A. Nasonova Research Institute of Rheumatology, Moscow, Russian Federation.
28
European League Against Rheumatism, Zurich, Switzerland.
29
Cyprus League against Rheumatism, Nicosia, Cyprus.
30
Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway.
31
Department of Rheumatology and Immunology, Beijing University People's Hospital, Beijing, China.
32
Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Paris-Sud, Université Paris-Sud, INSERM U1184, Center for Immunology of viral Infections and Autoimmune Diseases (IMVA), Le Kremlin Bicêtre, France.
33
Institute of Infection, Immunity and Inflammation, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK.
34
Organización Médica de Investigación, Buenos Aires, Argentina.
35
Department of Medicine, University of Queensland, Queensland, Australia.
36
Institute of Rheumatology and Clinic of Rheumatology, Charles University, Prague, Czech Republic.
37
National Institute of Rheumatology and Physiotherapy, Semmelweis University, Budapest, Hungary.
38
Rheumatology Department, FHU ACRONIM, Pellegrin Hospital and UMR CNRS 5164, Bordeaux University, Bordeaux, France.
39
Department of Rheumatology, Bernhoven, Uden, The Netherlands.
40
University of Cologne, Cologne, Germany.
41
Division of Rheumatology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA.
42
Serviço de Reumatologia, Centro Hospitalar e Universitário de Coimbra Praceta Mota Pinto, Coimbra, Portugal.
43
Section for Outcomes Research, Center for Medical Statistics, Informatics, and Intelligent Systems, Medical University of Vienna, Vienna, Austria.
44
Keio University School of Medicine, Keio University Hospital, Tokyo, Japan.
45
Department of Development and Regeneration, Skeletal Biology and Engineering Research Center, KU Leuven, Leuven, Belgium.
46
Department of Rheumatology, University Hospitals Leuven, Leuven, Belgium.
47
Department Medical Humanities, VU Medical Centre, Amsterdam, The Netherlands.

Abstract

Recent insights in rheumatoid arthritis (RA) necessitated updating the European League Against Rheumatism (EULAR) RA management recommendations. A large international Task Force based decisions on evidence from 3 systematic literature reviews, developing 4 overarching principles and 12 recommendations (vs 3 and 14, respectively, in 2013). The recommendations address conventional synthetic (cs) disease-modifying antirheumatic drugs (DMARDs) (methotrexate (MTX), leflunomide, sulfasalazine); glucocorticoids (GC); biological (b) DMARDs (tumour necrosis factor (TNF)-inhibitors (adalimumab, certolizumab pegol, etanercept, golimumab, infliximab), abatacept, rituximab, tocilizumab, clazakizumab, sarilumab and sirukumab and biosimilar (bs) DMARDs) and targeted synthetic (ts) DMARDs (Janus kinase (Jak) inhibitors tofacitinib, baricitinib). Monotherapy, combination therapy, treatment strategies (treat-to-target) and the targets of sustained clinical remission (as defined by the American College of Rheumatology-(ACR)-EULAR Boolean or index criteria) or low disease activity are discussed. Cost aspects were taken into consideration. As first strategy, the Task Force recommends MTX (rapid escalation to 25 mg/week) plus short-term GC, aiming at >50% improvement within 3 and target attainment within 6 months. If this fails stratification is recommended. Without unfavourable prognostic markers, switching to-or adding-another csDMARDs (plus short-term GC) is suggested. In the presence of unfavourable prognostic markers (autoantibodies, high disease activity, early erosions, failure of 2 csDMARDs), any bDMARD (current practice) or Jak-inhibitor should be added to the csDMARD. If this fails, any other bDMARD or tsDMARD is recommended. If a patient is in sustained remission, bDMARDs can be tapered. For each recommendation, levels of evidence and Task Force agreement are provided, both mostly very high. These recommendations intend informing rheumatologists, patients, national rheumatology societies, hospital officials, social security agencies and regulators about EULAR's most recent consensus on the management of RA, aimed at attaining best outcomes with current therapies.

KEYWORDS:

DMARDs (biologic); DMARDs (synthetic); Disease Activity; Rheumatoid Arthritis; Treatment

PMID:
28264816
DOI:
10.1136/annrheumdis-2016-210715
[Indexed for MEDLINE]
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