MADRID—The latest European League Against Rheumatism (EULAR) recommendations for the management of rheumatoid arthritis give a somewhat greater nod to the use of combination conventional disease-modifying antirheumatic drugs (DMARDs) than past recommendations did, but leaves monotherapy with methotrexate as a perfectly acceptable first-line treatment.
The recommendations also keep all biologic DMARDs—such as tumor necrosis factor (TNF) inhibitors—as second-line treatments, according to a presentation by Josef Smolen, MD, chair of rheumatology at the Medical University of Vienna, who spoke on behalf of the 33-member task force that wrote the updated recommendations. He made his remarks in a presentation at the EULAR 2013 Annual European Congress of Rheumatology, held June 12–15.
The task force included an infectious disease specialist, a health economist, four patient representatives and three fellows who performed systematic literature reviews on synthetic DMARDs, biologic DMARDs, and safety concerns.
Treatment Recommendations
The task force recommends that biological DMARDs should be started, along with methotrexate, in patients who don’t respond sufficiently to conventional DMARDs and have risk factors for bad outcome. Those biologics, the task force decided, can include TNF inhibitors, abatacept, or tocilizumab.
There has been “no preference given to any agent as a first biological,” Dr. Smolen said.
The task force also adjusted its recommendations on glucocorticoid use, now saying that “low-dose glucocorticoids should be considered as part of the initial treatment strategy (in combination with one or more conventional synthetic DMARDs) for up to six months, but should be tapered as rapidly as clinically feasible.”
The task force’s recommendations also have a place for tofacitinib, saying it “may be considered after biological treatment has failed.” The recommendations were finalized before the European Medicines Agency refused marketing authorization for the drug. Tofacitinib has been approved in the U.S., Japan, and Russia.
“EULAR recommendations are of a general nature and not only intended for Europe,” Dr. Smolen said.
Changes from 2010 Recommendations
EULAR’s 2010 RA recommendations caused a stir when monotherapy was expressly recommended as first-line treatment over combination conventional synthetic DMARDs. Some rheumatologists in the field felt that the evidence justified a more prominent role for combination therapy.
In the latest recommendations, the task force recommends either “conventional synthetic DMARD monotherapy or combination therapy” in DMARD-naive patients.
“The 2010 recommendations did not intend to say that the use of combination conventional synthetic DMARD therapy was wrong, but only that it was not needed,” Dr. Smolen said. “The 2013 task force reiterates the evidence-based view that conventional synthetic DMARD monotherapy is effective.