4
Treatment
Table 2. DMARD Initiation
Recommendations
Certainty of
Evidence
Initiation of treatment in DMARD-naive patients with moderate to high disease
activity
Methotrexate monotherapy is strongly recommended over:
• Hydroxychloroquine or sulfasalazine
Very low
a
/ Low
b
• bDMARD or tsDMARD monotherapy
Very low / Moderate
• Combination of methotrexate plus a non-TNF inhibitor
bDMARD or tsDMARD
c
Low / Very low
Methotrexate monotherapy is conditionally recommended over:
• Leflunomide Low
• Dual or triple csDMARD therapy
c
Moderate
• Combination of methotrexate plus a TNF inhibitor
c
Low
Initiation of a csDMARD without short-term (<3 months)
glucocorticoids is conditionally recommended over initiation
of csDMARD with short-term glucocorticoids.
Very low
Initiation of a csDMARD without longer-term (≥3 months)
glucocorticoids is strongly recommended over initiation of
csDMARD with longer-term glucocorticoids.
Moderate
Initiation of treatment in DMARD-naive patients with low disease activity
Hydroxychloroquine is conditionally recommended over other
csDMARDs.
Very low
Sulfasalazine is conditionally recommended over methotrexate. Very low
Methotrexate is conditionally recommended over leflunomide. Very low
Initiation of treatment in csDMARD treated, but methotrexate-naive, patients with
moderate to high disease activity
d
Methotrexate monotherapy is conditionally recommended over
combination of methotrexate plus a bDMARD or tsDMARD
c,e
Moderate / Very low
a
e first certainty of evidence applies to the first listed option.
b
e second certainty of evidence applies to the second listed option.
c
e direction of the beneficial effect is in favor of the non-preferred option.
d
Other recommendations for this patient population are the same as those for DMARD naive patients.
e
e certainty of evidence is high for the combination of methotrexate plus a TNF inhibitor and
moderate for other bDMARDs.
