According to Dr. Smolen, the two updates of the ACR and EULAR guidelines are the closest to date in terms of recommending treat-to-target strategies and recommending first-line treatment with combination MTX and glucocorticoids. Older treatment recommendations were to combine csDMARDs.
You Might Also Like
Explore This IssueJuly 2017
Also By This Author
Points where they differ include the inclusion in the 2016 EULAR guidelines of not-yet-approved agents, sirukumab and sarilumab (although this latter drug has since been recommended for approval by the European Medicines Union), as well as baricitinib, which was recently licensed in Europe. The ACR guidelines differ as well in their recommendation of biologics as mono- or combination therapy.
Dr. Bykerk notes that the EULAR recommendations are more proscriptive than the ACR guideline about the early use of csDMARDs, with MTX as the specific agent to use for first-line treatment, as well as the use of another csDMARD (specifically SSZ or leflunomide) if MTX is not tolerated.
“Importantly, [EULAR] will not fully endorse that ‘triple’ DMARD or any specific combination of csDMARDs should be mandatory,” she says. “However, they also recommend concomitant csDMARDs should be used with bDMARDs, except in the cases of tocilizumab and tofacitinib.”
Dr. Smolen points out that the guideline does recommend concomitant use of csDMARDs for all bDMARDs and recommends monotherapy, preferably IL-6 or JAK inhibitors, only if all csDMARDs are contraindicated.
Mary Beth Nierengarten is a freelance medical journalist based in Minneapolis.
Nomenclature for Disease-Modifying Anti-Rheumatic Drugs
The 2016 EULAR guidelines use a set of acronyms to denote the varying classes of disease-modifying anti-rheumatic drugs (DMARDs) now available. Dr. Bykerk recommends the wide adoption of these acronyms in articles going forward to enable rapid understanding of what specific DMARDs are being discussed. She also suggests subclassifying biologic DMARDs.
Specific acronyms for DMARDs:
- Conventional synthetic DMARDs (csDMARDs): This group includes methotrexate, leflunomide, sulfasalazine and hydroxychloroquine;
- Targeted synthetic DMARDs (tsDMARDs): This group includes tofacitinib and baricitinib; and
- Biologic DMARDs (bDMARDs):
- Biological originator DMARDs (boDMARDs); and
- Biosimilar DMARDs (bsDMARDs).
- Singh JA, Saag, KG, Bridges SL Jr., et al. 2015 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res (Hoboken). 2016 Jan;68(1):1–25.
- Singh JA, Furst DE, Bharat A, et al. 2012 Update of the 2008 American College of Rheumatology recommendations for the use of disease-modifying antirheumatic drugs and biologic agents in the treatment of rheumatoid arthritis. Arthritis Care Res (Hoboken). 2012 May;64(5):625–639.
- Saag KG, Teng GG, Patkar NM, et al. American College of Rheumatology 2008 recommendations for the use of nonbiologic and biologic disease-modifying antirheumatic drugs in rheumatoid arthritis. Arthritis Rheum. 2008 Jun 15;59(6):762–784.
- Smolen JS, Landewé R, Bijlsma J, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2016 update. Ann Rheum Dis. 2017 Jun;76(6):960–977.
- Smolen JS, Landewé R, Breedveld FC, et al. EULAR recommendation for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2013 update. Ann Rheum Dis. 2014 Mar;73(3):492–509.
- Smolen JS, Landewé R, Breedveld FC, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological diease-modifying antirheumatic drugs. Ann Rheum Dis. 2010 Jun;69(6):964–975.