3
Treatment
Table 1. Guiding Principles
RA requires early evaluation, diagnosis, and management.
Treatment decisions should follow a shared decision-making process.
Treatment decisions should be re-evaluated within a minimum of three months based
on efficacy and tolerability of the disease modifying anti-rheumatic drugs (DMARD(s))
chosen.
Disease activity levels refer to those calculated using RA disease activity measures
endorsed by the ACR.
Recommendations are intended for the general RA patient population and assume that
patients do not have contraindications to the options under consideration.
Recommendations are limited to DMARDs approved by the U.S. Food and Drug
Administration (FDA) for treatment of RA:
• Conventional synthetic DMARDs (csDMARDs): hydroxychloroquine, sulfasalazine,
methotrexate, leflunomide
• Biologic DMARDs (bDMARDs): tumor necrosis factor (TNF) inhibitors
(etanercept, adalimumab, infliximab, golimumab, certolizumab pegol), T cell co-
stimulatory inhibitor (abatacept), IL-6 receptor inhibitors (tocilizumab, sarilumab),
anti-CD20 antibody (rituximab)
a
• Targeted synthetic DMARDs (tsDMARDs): JAK inhibitors (tofacitinib, baricitinib,
upadacitinib)
(See Table 7)
Triple therapy refers to hydroxychloroquine, sulfasalazine, and either methotrexate or
leflunomide.
Serious infection refers to an infection requiring intravenous antibiotics or hospitalization.
Biosimilars are considered equivalent to FDA-approved originator bDMARDs.
Recommendations referring to bDMARDs exclude rituximab unless patients have
had an inadequate response to TNF inhibitors (in order to be consistent with FDA
approval) or have a history of lymphoproliferative disorder for which rituximab is an
approved therapy.
Treat to target refers to a systematic approach involving frequent monitoring of disease
activity using validated instruments and modification of treatment to minimize disease
activity with the goal of reaching a predefined target (low disease activity or remission).
Target refers to low disease activity or remission.
Recommendations specify that patients be at target (low disease activity or remission)
for at least six months prior to tapering.
Dose reduction refers to lowering the dose or increasing the dosing interval of a
DMARD. Gradual discontinuation of a DMARD is defined as gradually lowering the
dose of a DMARD and subsequently stopping it.
a
Anakinra was not included due to infrequent use for patients with RA.
