EULAR Recommendations for the Management of Rheumatoid Arthritis with Synthetic and Biological Disease-modifying Antirheumatic Drugs: 2016 Update
The EULAR 2016 recommendations update, based on three systematic literature reviews (SLRs) and expert opinion, comprises four overarching principles and 12 recommendations compared with 14, respectively, in 2013. These recommendations intend to inform regarding EULAR’s most recent consensus on the management of RA, with the aim of attaining the best outcomes with current therapies.
All DMARD types: csDMARDs, bDMARDs, tsDMARD and bsDMARD are addressed, and cost aspects are taken into consideration. As a first strategy, the Task Force recommends MTX + short-term glucocorticoids aiming for >50% improvement within 3 months, and target attainment (remission or at least low disease activity) within 6 months.
Of note, the recommendations have been adjusted with respect to the use of tsDMARDs. If the treatment target is not achieved with the first csDMARD strategy, when poor prognostic factors are present adding a bDMARD or a tsDMARD (tofacitinib or baricitinib, where approved) should be considered, whereas current practice is to start a bDMARD. In patients who are unable to use csDMARDs as comedication, IL-6 inhibitors and tsDMARDs may have advantages over other bDMARDs. If treatment with a bDMARD or tsDMARD fails, any other bDMARD or tsDMARD is recommended.
If failure occurred with a TNF inhibitor (TNFi), patients may receive another TNFi or an agent with another mechanism of action. If a patient is in sustained remission, bDMARDs can be tapered.
For each recommendation, levels of evidence and agreement were mostly very high.