EULAR类风湿性关节炎DMARDs治疗指南

 The management of rheumatoid arthritis (RA) has changed dramatically over the past 30 years. Few therapeutic agents existed then, which were either minimally or not efficacious, because of toxicity and the fact that optimal dosing and onset of action had not yet been elucidated for some agents.Available therapies were started late rather than early in the course of the disease. Early arthritis clinics were emerging,and their successes fuelled reappraisal of the classification criteria then available that focused primarily on longstanding disease. A therapeutic target had not yet been defined, because relief of symptoms appeared to be the most important goal and the concept of aiming at disease states like remission or low disease activity was at best aspirational.

Recommendation

1. Glossary and definitions

2. Overarching principles

A. Treatment of patients with RA should aim at the best care and must be based on a shared decision between the patient and the rheumatologist.

B. Treatment decisions are based on disease activity and other patient factors, such as progression of structural damage,comorbidities and safety issues.

C. Rheumatologists are the specialists who should primarily
care for patients with RA.

D. RA incurs high individual, medical and societal costs, all of which should be considered in its management by the treating rheumatologist.

3. Recommendations
General aspects

Individual recommendations

1. Therapy with DMARDs should be started as soon as the diagnosis of RA is made.

2. Treatment should be aimed at reaching a target of sustained remission or low disease activity in every patient.

3. Monitoring should be frequent in active disease (every 1–3 months); if there is no improvement by at most 3 months after the start of treatment or the target has not been reached by 6 months, therapy should be adjusted.

4. MTX should be part of the first treatment strategy.

5. In patients with a contraindication to MTX (or early intolerance), leflunomide or sulfasalazine should be considered as part of the (first) treatment strategy.

6. Short-term GC should be considered when initiating or changing csDMARDs, in different dose regimens and routes of administration, but should be tapered as rapidly as clinically feasible.

7. If the treatment target is not achieved with the first csDMARD strategy, in the absence of poor prognostic factors,other csDMARDs should be considered.

8. If the treatment target is not achieved with the first csDMARD strategy, when poor prognostic factors are present,addition of a bDMARD* or a tsDMARD* should be considered;current practice would be to start a bDMARD§.

9. bDMARDs* and tsDMARDs# should be combined with a csDMARD; in patients who cannot use csDMARDs as comedication, IL-6 pathway inhibitors and tsDMARDs may have some advantages compared with other bDMARDs.

10. If a bDMARD* or tsDMARD§ has failed, treatment with another bDMARD or a tsDMARD should be considered; if one TNF-inhibitor therapy has failed, patients may receive another TNF-inhibitor or an agent with another mode of action.

11. If a patient is in persistent remission after having tapered GC, one can consider tapering bDMARDs, especially if this treatment is combined with a csDMARD.

12. If a patient is in persistent remission, tapering the csDMARD could be considered.

4. The 2016 EULAR updated recommendations

5. Algorithm based on the 2016 European League Against Rheumatism (EULAR) recommendations on rheumatoid arthritis (RA) management.