Clinical Guidance & Recommendation Updates for Vasculitis, axSpA & More

A new recommendation from EULAR is if a patient has recurrent uveitis or active inflammatory bowel disease, then preference should be given to a TNFα inhibitor, and patients with psoriasis should receive IL-17A inhibitor therapy.

Dr. Ramiro provided an important statement on the recommendation that absence of response to treatment should trigger reevaluation of the diagnosis and consideration for the presence of comorbidities that may be limiting effectiveness of treatment. In cases where additional treatment with a biologic DMARD or targeted synthetic DMARD is still indicated, a TNFα inhibitor, IL-17 inhibitor or JAK inhibitor is reasonable to consider. If a patient does achieve sustained remission, then tapering of a biologic DMARD could be considered.

Rheumatoid Arthritis

Dr. Smolen

Josef Smolen, MD, professor of internal medicine and chairman, Department of Rheumatology, Vienna General Hospital, University of Vienna, Austria, concluded the session by discussing recommendations on the management of rheumatoid arthritis. In 2021, the ACR published an updated guideline on the management of rheumatoid arthritis (see highlights online).³ One departure EULAR takes from the 2021 ACR guideline is the EULAR recommendation in favor of combining a first-line DMARD, such as methotrexate, with short-term glucocorticoids.

Dr. Smolen noted the ACR guideline had a very low to moderate level of evidence in the recommendation against use of short-term glucocorticoids as part of initial therapy.³ He acknowledged that glucocorticoids can increase the risk of certain adverse outcomes for patients, such as via cardiovascular risks, but he noted that it is unclear if these risks are substantially increased in the short term as well as the long term. He also explained that the NORD-STAR trial indicated that methotrexate combined with glucocorticoids was noninferior to methotrexate combined with certolizumab, as well as to methotrexate combined with tocilizumab, in achieving a 15% reduction in Clinical Disease Activity Index (CDAI) score at 24 weeks.⁴

On the subject of JAK inhibitor therapy, Dr. Smolen pointed out the ORAL Surveillance study showed an increased risk of major adverse cardiac events (MACE) and cancers in patients treated with tofacitinib compared with those receiving a TNFα inhibitor.⁵ This has been an important and complex subject because other literature at least questions if these associations hold true across all patients with RA. Also, because the ENTRACTE study did not show increased MACE risk with tocilizumab vs. etanercept, the increased MACE risk in the ORAL Surveillance study is unlikely to be due to inhibition of IL-6 signaling.⁶