6
Treatment
Table 5. Recommendations for Patients with Established RA
a
Recommendations
Level of
Evidence
1. Regardless of disease activity level, use a treat-to-target strategy
rather than a non-targeted approach.
Moderate
2. If the disease activity is low, in patients who have never taken a
DMARD, use DMARD monotherapy (MTX preferred) over a
TNFi.
Low
3. If the disease activity is moderate or high in patients who have never
taken a DMARD:
• use DMARD monotherapy (MTX preferred) over tofacitinib. High
• use DMARD monotherapy (MTX preferred) over combination
DMARD therapy.
Moderate
4. If disease activity remains moderate or high despite DMARD
monotherapy, use combination traditional DMARDs or add a
TNFi or a non-TNF biologic or tofacitinib (all choices with or
without MTX, in no particular order of preference), rather than
continuing DMARD monotherapy alone.
Moderate to
Very Low
5. If disease activity remains moderate or high despite TNFi therapy
in patients who are currently not on DMARDs, add one or two
DMARDs to TNFi therapy rather than continuing TNFi therapy
alone.
High
6. If disease activity remains moderate or high despite use of a single
TNFi:
• use a non-TNF biologic, with or without methotrexate, over another
TNFi with or without methotrexate.
Low to Very Low
• use a non-TNF biologic, with or without methotrexate, over
tofacitinib with or without methotrexate.
Very Low
b
7. If disease activity remains moderate or high despite use of a single
non-TNF biologic, use another non-TNF biologic, with or without
methotrexate, over tofacitinib, with or without methotrexate.
Very Low
b
8. If disease activity remains moderate or high despite use of multiple
(2+) sequential TNFi therapies, first use a non-TNF biologic, with
or without methotrexate, over another TNFi or tofacitinib (with or
without methotrexate).
Very Low
9. If the disease activity still remains moderate or high despite the use of
multiple TNFi therapies, use tofacitinib, with or without methotrexate,
over another TNFi, with or without methotrexate, if use of a non-TNF
biologic is not an option.
Low
