Treatment of Rheumatoid Arthritis
Based on guidelines from the American College of Rheumatology.
Symptomatic Early RA
General
Low Disease Activity
If the disease activity is low, in patients who have never taken a DMARD, use DMARD monotherapy (MTX preferred) over double therapy.
Moderate or High Disease Activity
If the disease activity is moderate or high, in patients who have never taken a DMARD, use DMARD monotherapy over double therapy.
If the disease activity is moderate or high, in patients who have never taken a DMARD, use DMARD monotherapy over triple therapy.
If disease activity remains moderate or high despite DMARD monotherapy (with or without glucocorticoids), use combination DMARDs or a TNFi or a non-TNF biologic (all choices with or without MTX, in no particular order of preference), rather than continuing DMARD monotherapy alone.
If disease activity remains moderate or high despite DMARDs, use a TNFi monotherapy over tofacitinib monotherapy.
If disease activity remains moderate or high despite DMARDs, use a TNFi + MTX over tofacitinib + MTX.
If disease activity remains moderate of high despite DMARD, add low-dose glucocorticoids.
Established RA
General
Low Disease Activity
If the disease activity is low, in patients who have never taken a DMARD, use DMARD monotherapy (MTX preferred) over a TNFi.
Moderate or High Disease Activity
If the disease activity is moderate or high, in patients who have never taken a DMARD, use DMARD monotherapy (MTX preferred) over tofacitinib.
If the disease activity is moderate or high, in patients who have never taken a DMARD, use DMARD monotherapy (MTX preferred) over combination DMARD therapy.
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.
If the 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.
If the disease activity remains moderate or high despite use of a single TNFi, use a non-TNF biologic, with or without MTX, over another TNFi with or without MTX.
If the disease activity remains moderate or high despite use of a single TNFi, use a non-TNF biologic, with or without MTX, over tofacitinib with or without MTX.
If the disease activity remains moderate or high despite use of a single non-TNF biologic, use another non-TNF biologic, with or without MTX, over tofacitinib, with or without MTX.
If the disease activity remains moderate or high despite use of multiple (2+) sequential TNFi therapies, first use a non-TNF biologic, with or without MTX, over another TNFi or tofacitinib (with or without MTX).
If the disease activity still remains moderate or high despite the use of multiple TNFi therapies, use tofacitinib, with or without MTX, over another TNFi, with or without MTX, if use of a non-TNF biologic is not an option.
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 MTX, over tofacitinib.
If disease activity remains moderate or high despite use of at least one TNFi and more than one non-TNF biologic, use tofacitinib, with or without MTX, over another TNFi.
Disease Flare
Remission
If the patient is in remission, taper TNFi, non-TNF biologic, or tofacitinib.
High-risk Comorbidities
CHF
Use combination DMARDs or non-TNF bioogic or tofacitinib over TNFi.
Hepatitis B
Hepatitis C
If receiving/received effective antiviral treatment, same recommendations as in patients without this condition.
Malignancy
Use DMARDs over biologics in previously treated or untreated melanoma.
Use DMARDs over tofacitinib in previously treated or untreated melanoma.
Use DMARDs over biologics in previously treated or untreated non-melanoma.
Use DMARDs over tofacitinib in previously treated or untreated non-melanoma.
If previously treated lymphoproliferative disorder, use rituximab over TNFi.
If previously treated lymphoproliferative disorder, use combination DMARD or abatacept or tocilizumab over TNFi.
What do the icons mean?
How strong is the ACR's recommendation?
Strong recommendation
Intervention's desirable effects clearly outweigh undesirable effects.Moderate recommendation
Further research likely to impact confidence in estimate of effect.Conditional recommendation
Uncertainty in tradeoffs between desirable & undesirable effects of intervention.Weak recommendation
Uncertainty in tradeoffs between desirable & undesirable effects of intervention.High quality evidence
Further research unlikely to change guideline authors' confidence in estimate of effect.Moderate to high quality evidence
Moderate quality evidence
Further research likely to impact confidence in estimate of effect.Low quality evidence
Further research expected to have important impact in confidence in estimate of effect.Very low to high quality evidence
Very low to moderate quality evidence
Very low to low quality evidence
Very low quality evidence
Effect is very uncertain.