{"id":1064,"date":"2022-11-30T11:25:51","date_gmt":"2022-11-30T11:25:51","guid":{"rendered":"https:\/\/blogs.bmj.com\/rheumsummaries\/?p=1064"},"modified":"2022-11-30T11:32:04","modified_gmt":"2022-11-30T11:32:04","slug":"updated-managing-ra","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/rheumsummaries\/2022\/11\/30\/updated-managing-ra\/","title":{"rendered":"Updated: Managing RA"},"content":{"rendered":"

This is the lay version of the EULAR recommendations for the management of rheumatoid arthritis using synthetic and biologic disease-modifying antirheumatic drugs. The original publication can be downloaded from the EULAR website: <\/span>www.eular.org<\/span><\/a>.<\/span><\/p>\n

Smolen JS, Landew\u00e9 RBM, Bergstra SA, et alEULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 updateAnnals of the Rheumatic Diseases Published Online First: 10 November 2022. doi: 10.1136\/ard-2022-223356<\/span><\/a><\/p>\n

Introduction<\/b><\/p>\n

EULAR gives advice to doctors, nurses, and patients about the best way to treat and manage diseases. In 2022, EULAR updated its recommendations on the management and treatment of people with rheumatoid arthritis (sometimes shortened to RA). Since the 2019 update, no new drug class has been approved for use in people with rheumatoid arthritis, but there is important new evidence about safety.<\/span><\/p>\n

Doctors, nurses, other health professionals and patients worked together to develop this advice. The patients in the team ensured that the patient point of view was included. The authors looked at the evidence for three specific groups of drugs for people with rheumatoid arthritis.<\/span><\/p>\n

What do we already know?<\/b><\/p>\n

Rheumatoid arthritis is a condition where the joints become stiff, painful and damaged due to the immune system attacking the body\u2019s own tissues and causing inflammation. These recommendations include information on three types of disease modifying anti-rheumatic drugs (often shortened to DMARDs) that are used to treat rheumatoid arthritis. These drugs aim to change the course of the disease by reducing inflammation, and can prevent flares and disease worsening. They can also help to improve function and stop the progression of joint damage.<\/span><\/p>\n

The three different types of DMARDs included in these recommendations are:<\/span><\/p>\n

    \n
  1. Conventional synthetic<\/b> DMARDs (sometimes shortened to csDMARDs).<\/span><\/li>\n<\/ol>\n

    This includes methotrexate, leflunomide, and sulfasalazine.<\/span><\/p>\n

      \n
    1. Biologic<\/b> DMARDs (also called bDMARDs, biologics or biologicals).<\/span><\/li>\n<\/ol>\n

      The bDMARDs used in rheumatoid arthritis include tumour necrosis factor inhibitors (TNFi),<\/span><\/p>\n

      interleukin-6 inhibitors (IL-6i), rituximab and abatacept. The individual TNFi drugs are adalimumab, certolizumab pegol, etanercept, golimumab, and infliximab. This also includes biosimilars. The individual IL-6i are tocilizumab and sarilumab.<\/span><\/p>\n

        \n
      1. Targeted synthetic<\/b> DMARDs (shortened to tsDMARDs).<\/span><\/li>\n<\/ol>\n

        The tsDMARDs used in rheumatoid arthritis are all Janus kinase inhibitors (JAKi).<\/span><\/p>\n

        The individual drugs in this class are tofacitinib, baricitinib, filgotinib, and upadacitinib.<\/span><\/p>\n

        The EULAR recommendations on the management of people with rheumatoid arthritis were first written in 2010, and have been updated regularly. The 2022 update is based on new evidence that has become available since the last version in 2019. EULAR also considered two important publications from other experts. In 2021, the US Food and Drug Administration \u2013 the body that makes decisions on which drugs can be used in the United States \u2013 warned about cardiovascular and malignancy risks with tofacitinib compared to TNFi. And then, the American College of Rheumatology decided to discourage use of glucocorticoids, reasoning that the toxicity outweighs the benefits. EULAR has looked at the evidence for both of these points when developing the new 2022 recommendations. In addition, all new evidence regarding efficacy and dose-reduction upon achievement of the desired good outcome was assessed.<\/span><\/p>\n

        What do the recommendations say?<\/b><\/p>\n

        In total, there are 5 overarching principles and 11 recommendations. The principles say that rheumatologists are the specialists who should primarily care for people with rheumatoid arthritis, and treatment should aim at best care and be based on a shared decision between the patient and their rheumatologist. This decision should consider each person\u2019s individual disease activity, safety issues and other factors, such as comorbidities and progression of structural damage. People with rheumatoid arthritis require access to multiple drugs with different modes of action, and they might need to try different therapies at different points\u00a0<\/span>in their life. Finally, the principles acknowledge that rheumatoid arthritis has high individual, medical and societal costs, all of which should be considered in its management.<\/span><\/p>\n

        Each recommendation is based on the best current knowledge from studies of scientific evidence or expert opinion. The more stars a recommendation has the stronger the evidence is. However, recommendations with limited scientific evidence may be important, because the experts can have a strong opinion even when the published evidence may be lacking.<\/span><\/p>\n

        One star (*) means it is a recommendation with limited scientific evidence.<\/span><\/p>\n

        Two stars (**) means it is a recommendation with some scientific evidence.<\/span><\/p>\n

        Three stars (***) means it is a recommendation with quite a lot of scientific evidence.<\/span><\/p>\n

        Four stars (****) means it is a recommendation supported with a lot of scientific evidence.<\/span><\/p>\n

        Recommendations<\/b><\/p>\n