Starting RA Treatment Right

DMARDs recommended by EULAR as first line of treatment for rheumatoid arthritis

/ Author:  / Reviewed by: Robert Carlson, M.D

(RxWiki News) There are so many medications to treat rheumatoid arthritis that it can be hard to tell which one will work best. One group of experts is telling patients where they should start.

The European League Against Rheumatism (EULAR) has updated its recommendations for managing rheumatoid arthritis.

Among those recommendations is the advice to start treatment with traditional disease-modifying anti-rheumatic drugs (DMARDs) as soon as the patient is diagnosed with rheumatoid arthritis.

That's in contrast to starting with a newer class of medications known as biologics.

The EULAR recommends that biologics be used only when patients don't respond to those first DMARDs within six months.

"See a rheumatologist about RA treatments."

These recommendations were put together by the EULAR Task Force, which included Professor Josef Smolen from the Medical University of Vienna and Hietzing Hospital in Vienna.

According to Professor Smolen, the recommendations were based on three large reviews of past studies that looked at the safety and effectiveness of conventional DMARDs and biologics. 

Professor Smolen added that the recommendations address some common misunderstandings about similar guidelines released in 2010.

"As already stated in 2010, by advocating for the use of synthetic DMARDs, rather than biologics, as the first-line treatment this approach avoids the over-treatment of 20 to 50 percent of patients with early [rheumatoid arthritis], who will achieve the treatment target with such initial therapy," he said.

In other words, the recommendation to start early treatment with conventional DMARDs is aimed at lowering disease activity without unnecessarily using biologics, which have been shown to have serious side effects in some cases.

The EULAR Task Force recommendations specifically call for using the DMARD methotrexate, or a combination of methotrexate with other DMARDs, as soon as a patient is diagnosed with rheumatoid arthritis.

The recommendations also allow patients and their doctors to consider using low-dose glucocorticoids — a type of steroid medication — in combination with DMARDs for up to six months. But patients should be weaned off these steroids as soon as possible.

If a patient don't respond well to initial treatment within six months, and if the outlook doesn't seem good, it may be time to turn to biologics.

The recommended biologics include medications such as TNF-inhibitors, abatacept (brand name Orencia) and tocilizumab (brand name Actemra). In some cases, patients may also be treated with rituximab (brand name Rituxan). 

When patients don't respond to their first biologic, the Task Force recommends that they receive another biologic. If these biologic treatments still don't work, the recommendations say that patients and their doctors can consider tofacitinib (brand name Xeljanz).

Even though tofacitinib has yet to be approved in Europe, " has been approved by the US Food and Drug Administration as well as in Japan and Russia," Professor Smolen said in a press release.

According to Professor Smolen, tofacitinib has been shown to be effective in study settings. However, he added, more research is needed to show that this medication is safe and effective in a real-world setting. 

Until that research is done, "...tofacitinib is only recommended after at least one biological has failed — in fact, many Task Force members felt it should be used after two biological treatment failures," said Professor Smolen.

If a patient reaches remission (inactive rheumatoid arthritis) and has been taken off steroids, the EULAR Task Force recommends that doctors consider weaning patients off of biologics, especially if that treatment is in combination with conventional DMARDs. 

If remission lasts over the long term, doctors can think about cautiously lowering the dosage of their patients' DMARDs.

These treatment recommendations are not the only part of the guidelines the EULAR has issued. The organization also addressed issues related to patients' overall care.

The guidelines suggest that rheumatologists be the main healthcare provider for patients with rheumatoid arthritis. They also call for check-ups on disease activity every one to three months and to consider changes to treatment if patients don't improve within three months or if the goal of treatment has not been met within six months.

Finally, the recommendations say that the decision to start or change treatment should be shared between patients and their doctor.

Reviewed by: 
Review Date: 
July 2, 2013
Last Updated:
July 25, 2013