Treatment of Rheumatoid Arthritis
Based on guidelines from the American College of Rheumatology.
These guideline summaries are shared for educational purposes only and are not intended to direct patient care. For detail on the specific recommendations and information about the evidence considered by the guideline developer, we encourage you to go to the original guideline statement cited below.
Symptomatic Early RA
Regardless of disease activity level, use a treat-to-target strategy rather than a non-targeted approach.
If the disease activity is low, in patients who have never taken a DMARD, use DMARD monotherapy (MTX preferred) over double therapy.
If the disease activity is low, in patients who have never taken a DMARD, use DMARD monotherapy (MTX preferred) over triple therapy.
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.
If disease activity remains moderate of high despite biologic therapies, add low-dose glucocorticoids.
If disease flares, add short-term glucocorticoids at the lowest possible dose and for the shortest possible duration.
Established RA
Regardless of disease activity level, use a treat-to-target strategy rather than a non-targeted approach.
If the disease activity is low, in patients who have never taken a DMARD, use DMARD monotherapy (MTX preferred) over a TNFi.
If disease activity is low, continue DMARD therapy.
If disease activity is low, continue TNFi, non-TNF biologic, or tofacitinib rather than discontinuing respective medication.
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.
If disease activity remains moderate or high despite use of DMARD, TNFi, or non-TNF biologic therapy, add short-term, low-dose glucocorticoid therapy.
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.
If the patient is in remission, taper DMARD therapy.
If the patient is in remission, taper TNFi, non-TNF biologic, or tofacitinib.
If the patient's disease is in remission, do not discontinue all RA therapies.
High-risk Comorbidities
Use combination DMARDs or non-TNF bioogic or tofacitinib over TNFi.
If CHF worsening on current TNFi therapy, use combination DMARDs or non-TNF biologic or tofacitinib over another TNFi.
If receiving/received effective antiviral treatment, same recommendations as in patients without this condition.
If receiving/received effective antiviral treatment, same recommendations as in patients without this condition.
If not receiving/received effective antiviral treatment, use DMARDs over TNFi.
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.
If previously treated solid organ malignancy, same recommendations as in patients without this condition.
Use combination DMARD over TNFi.
Use abatacept over TNFi.