7
Table 5. Recommendations for Patients with Established RA
a
(cont'd)
Recommendations
Level of
Evidence
10. If disease activity remains moderate or high despite use of at least one
TNFi and at least one non-TNF-biologic:
• first use another non-TNF biologic, with or without methotrexate,
over tofacitinib.
Very Low
• If disease activity remains moderate or high, use tofacitinib, with or
without methotrexate, over another TNFi.
Very Low
11. If disease activity remains moderate or high despite use of DMARD,
TNFi, or non-TNF biologic therapy, add short-term, low dose
glucocorticoid therapy.
High to Moderate
12. If disease flares in patients on DMARD, TNFi, or non-TNF biologic
therapy, add short-term glucocorticoids at the lowest possible dose and
the shortest possible duration.
Very Low
13. If the patient is in remission:
• taper
c
DMARD therapy. Low
d
• taper TNFi, non-TNF biologic, or tofacitinib (please also see #15). Moderate to
Very Low
d
14. If disease activity is low:
• continue DMARD therapy. Moderate
• continue TNFi, non-TNF biologic or tofacitinib rather than
discontinuing respective medication.
High to
Very Low
15. If the patient's disease is in remission, DO NOT discontinue all
RA therapies.
Very Low
b
See Table 9 for explanation of the Green and bolded and Yellow and italicized recommendations.
a
e definition of established RA is based on the 1987 ACR RA Classification criteria,
2
since the
2010 ACR/EULAR RA classification allows classification of a much earlier disease state.
3
b
No studies were available, leading to very low quality evidence, and the recommendation was based
on clinical experience.
c
Tapering means scaling back therapy (reducing dose or dosing frequency), not discontinuing it.
Tapering should be considered an option and not be mandated. If done, tapering must be conducted
slowly and carefully, watching for increased disease activity and flares. Even for RA patients whose
RA is in remission, there is some risk of flare when tapering.
d
Evidence is rated low quality or moderate to very low quality because some evidence reviewed for
this recommendation was indirect and included studies with discontinuation rather than tapering of
therapy or since studies involved patients achieving low disease activity rather than remission.
