Rheumatoid nodules: For patients with subcutaneous rheumatoid nodules and moderate to high disease activity, methotrexate is conditionally recommended over alternative conventional synthetic DMARDs. For patients with progressive nodules who are already on methotrexate, switching to a non-methotrexate DMARD is conditionally recommended over the continuation of methotrexate.
Lung disease: Often, the subject of pulmonary disease and RA treatment arises in clinical practice, and it is addressed in the guideline. For patients with incidental, mild, stable airway or parenchymal lung disease with moderate to high RA disease activity, methotrexate is conditionally recommended over other DMARDs. While pre-existing lung disease is a risk factor for methotrexate-related pneumonitis, the overall risk of worsening lung disease attributable to methotrexate is uncertain. The recommendation was made in favor of methotrexate because of its important role as an anchor treatment in RA and the lack of alternatives with similar efficacy and/or superior long-term safety profiles.
Heart failure: In patients with heart failure who meet criteria for New York Heart Classification III or IV (i.e., class III: marked limitation of physical activity; less than ordinary physical activity leads to symptoms; and class IV: unable to carry on any physical activity without discomfort; symptoms of congestive heart failure present at rest) and have an inadequate response to conventional synthetic DMARDs, non-TNFi biologic therapy or targeted synthetic DMARD treatment is conditionally recommended over TNFi.
Liver disease: For patients with a history of hepatitis B, prophylactic antiviral therapy is strongly recommended in patients positive for hepatitis B core antibodies or who are starting rituximab treatment, even if they test negative for hepatitis B surface antigens. Prophylactic antiviral therapy is also strongly recommended for patients positive for hepatitis B surface antigens who are starting any biologic or targeted synthetic DMARD. Frequent monitoring is conditionally recommended for patients who are positive for hepatitis B core antibodies and negative for hepatitis B surface antigens if they are starting a non-rituximab, biologic DMARD or targeted synthetic DMARD treatment.
Methotrexate is also conditionally recommended over other DMARDs in patients with nonalcoholic fatty liver disease who are DMARD naive and have moderate to high disease activity, normal liver enzymes and function tests, and no advanced fibrosis.
Glucocorticoids: During the panel discussion, it was also noted that for patients who are DMARD naive and have moderate to high disease activity, DMARDs without short-term glucocorticoid use (i.e., less than three months) are conditionally recommended over DMARDs with short-term glucocorticoid use.
