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Management of rheumatoid arthritis (RA) is complex. The ever-expanding availability of new drugs requires that rheumatologists and patients constantly consider treatment strategies and targets aimed at both disease control and symptom relief while remaining cognizant of the increasing high cost of emerging medications. Given such complexity, guidelines to inform rheumatologists about the most recent developments on managing RA have been appearing every three years or so.
In 2015, the ACR published an updated guideline; previous versions were published in 2012 and 2008.1-3 Most recently, the European League Against Rheumatism (EULAR) released its RA guidelines updated in 2016; previous ones were published in 2013 and 2010.4-6 The frequency of these updated guidelines suggests the importance for rheumatologists to keep up with the fast pace of the evidence to ensure the many and new treatment options available are tailored to individual patients and offered to all patients. This is particularly important given the high cost of many of the agents, such as biologics, that limit their widespread use.
This is aptly stated in the 2016 EULAR guidelines: “Management recommendations on the approach to treating patients with RA have become increasingly useful in providing physicians, patients, payers, regulators and other healthcare suppliers with evidence-based guidance supported by the views of experts involved in many of these novel developments.”4
This article highlights key findings and recommendations from the most current EULAR RA guideline. Drawing on the most current evidence to date, the 2016 EULAR update continues to support treatment strategies and specific treatment recommendations found in previous EULAR and ACR guidelines. Both guidelines emphasize treat-to-target strategies aimed at disease control, along with symptom relief, and offer specific treatment recommendations to help patients achieve this goal. Importantly, they now highlight the need to achieve and maintain treatment control.
The following sections focus on specific, new evidence-based recommendations for first- and second-line treatments, as well as tapering patients off therapies once persistent remission is achieved.
Foundations for Treatment Decisions & Goals
One change to the 2016 EULAR guidelines is the higher emphasis placed on basing treatment decisions not only on disease activity, but importantly, on such patient factors as comorbidities. This change is reflected in the four overarching principles that the guidelines provide (see Table 1). As noted in Table 1, principle B—Treatment decisions are based on disease activity and other patient factors, such as progression of structural damage, comorbidities and safety issues—moved from being a recommendation in the 2010 guideline to foundational in the 2016 guideline, reflecting the importance of considering comorbidities in treatment decisions.