EULAR Backs MTX, DMARDs as First-Line for Early RA

As soon as rheumatoid arthritis (RA) is diagnosed, rheumatologists should start patients on methotrexate (MTX) or a combination of MTX and synthetic disease-modifying anti-rheumatic drugs (DMARDs), says the European Union League Against Rheumatism (EULAR).

If RA patients fail to respond to this first-line treatment within six months, or display poor prognostic factors, newly updated EULAR recommendations advise the use of biologic DMARDs with MTX – such as TNF-inhibitors, abatacept or tocilizumab or, under certain circumstances, rituximab.

The goal of the 2013 recommendations, based on literature reviews of the safety and effectiveness of biological and conventional DMARDs, is remission or low disease activity and avoiding overtreatment with biologics, stresses Josef S. Smolen, MD, lead author and a professor at the Medical University of Vienna, in a press release describing the forthcoming guidelines.

 “By advocating the use of synthetic DMARDs, rather than biologics as the first-line treatment, this approach avoids the over-treatment of 20-50% of patients with early RA, who will achieve the treatment target with such initial therapy,” Dr. Smolen says in a statement by the EULAR Task Force.

The 2013 EULAR RA Management Guidelines, to be published this fall,  also recommend:

•   Low-dose glucocorticoids, in combination with DMARDs, should be used for up to six months – with the proviso they be tapered as soon as clinically feasible.
•   Patients non-responsive to the first biologic should be given another.
•   If persistent remission is achieved and glucocorticoids have been tapered, rheumatologists should consider a taper of the biological DMARD.
•   In cases of sustained long-term remission, careful dose-reduction of conventional synthetic DMARDs can be considered.
•   Patients may be prescribed another TNF-inhibitor (or a biologic with a different mode of action) if they do not respond to the first one.
•  Tofacitinib (currently approved in the US by the FDA, in Japan and in Russia, but not by the European Medicines Agency) may be considered if at least one biologic fails.
•  Monitor disease activity every one to three months, altering therapy with shared decision-making if no improvement is seen in three months or if the target is not reached by six months.