EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2016 update.
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Smolen Josef S, Landewé Robert, Bijlsma Johannes, Burmester Gerd, Chatzidionysiou Katerina, Dougados Maxime, Nam Jackie, Ramiro Sofia, Voshaar Marieke, van Vollenhoven Ronald, Aletaha Daniel, Aringer Martin, Boers Maarten, Buckley Chris D, Buttgereit Frank, Bykerk Vivian, Cardiel Mario, Combe Bernard, Cutolo Maurizio, van Eijk-Hustings Yvonne, Emery Paul, Finckh Axel, Gabay Cem, Gomez-Reino Juan, Gossec Laure, Gottenberg Jacques-Eric, Hazes Johanna M W, Huizinga Tom, Jani Meghna, Karateev Dmitry, Kouloumas Marios, Kvien Tore, Li Zhanguo, Mariette Xavier, McInnes Iain, Mysler Eduardo, Nash Peter, Pavelka Karel, Poór Gyula, Richez Christophe, van Riel Piet, Rubbert-Roth Andrea, Saag Kenneth, da Silva Jose, Stamm Tanja, Takeuchi Tsutomu, Westhovens René, de Wit Maarten, van der Heijde Désirée
Аннотация
Recent insights in rheumatoid arthritis (RA) necessitated updating the European League Against Rheumatism (EULAR) RA management recommendations. A large international Task Force based decisions on evidence from 3 systematic literature reviews, developing 4 overarching principles and 12 recommendations (vs 3 and 14, respectively, in 2013). The recommendations address conventional synthetic (cs) disease-modifying antirheumatic drugs (DMARDs) (methotrexate (MTX), leflunomide, sulfasalazine); glucocorticoids (GC); biological (b) DMARDs (tumour necrosis factor (TNF)-inhibitors (adalimumab, certolizumab pegol, etanercept, golimumab, infliximab), abatacept, rituximab, tocilizumab, clazakizumab, sarilumab and sirukumab and biosimilar (bs) DMARDs) and targeted synthetic (ts) DMARDs (Janus kinase (Jak) inhibitors tofacitinib, baricitinib). Monotherapy, combination therapy, treatment strategies (treat-to-target) and the targets of sustained clinical remission (as defined by the American College of Rheumatology-(ACR)-EULAR Boolean or index criteria) or low disease activity are discussed. Cost aspects were taken into consideration. As first strategy, the Task Force recommends MTX (rapid escalation to 25 mg/week) plus short-term GC, aiming at >50% improvement within 3 and target attainment within 6 months. If this fails stratification is recommended. Without unfavourable prognostic markers, switching to-or adding-another csDMARDs (plus short-term GC) is suggested. In the presence of unfavourable prognostic markers (autoantibodies, high disease activity, early erosions, failure of 2 csDMARDs), any bDMARD (current practice) or Jak-inhibitor should be added to the csDMARD. If this fails, any other bDMARD or tsDMARD is recommended. If a patient is in sustained remission, bDMARDs can be tapered. For each recommendation, levels of evidence and Task Force agreement are provided, both mostly very high. These recommendations intend informing rheumatologists, patients, national rheumatology societies, hospital officials, social security agencies and regulators about EULAR's most recent consensus on the management of RA, aimed at attaining best outcomes with current therapies.