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American College of RheumatologyRheumatology2021advanced

Treatment of Rheumatoid Arthritis

Published by American College of Rheumatology · GRADE

44Recommendations
66References
7Tables
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Summary

AI-generated

This guideline updates recommendations for the pharmacologic management of rheumatoid arthritis, addressing treatment with conventional, biologic, and targeted synthetic DMARDs, the use of glucocorticoids, and DMARD use in specific high-risk patient populations.

rheumatoid arthritismethotrexatehydroxychloroquinesulfasalazineglucocorticoidsACRrheumatologyguidelines

Key Takeaways

  • 1
    Methotrexate is the strongly preferred initial DMARD for patients with moderate-to-high disease activity.
  • 2
    A treat-to-target strategy should be employed to achieve low disease activity or remission.
  • 3
    Glucocorticoid use should be minimized, and longer-term use is strongly discouraged due to significant toxicity.
  • 4
    Hydroxychloroquine or sulfasalazine is conditionally recommended as first-line therapy for low disease activity.
  • 5
    For tapering, continuing medications or gradual dose reduction is preferred over abrupt withdrawal once a patient is at target for at least 6 months.

What's New in This Version

Recommendations are no longer grouped by early versus established RA disease duration. Initial treatment with hydroxychloroquine or sulfasalazine is now recommended for low disease activity. Tapering recommendations now apply to patients in low disease activity or remission, not just remission. Added strong recommendations against longer-term use of glucocorticoids due to toxicity risks.

Key Recommendations

DMARD-naive patients with moderate-to-high disease activity

  • rec_1

    Methotrexate is strongly recommended over hydroxychloroquine or sulfasalazine for DMARD-naive patients with moderate-to-high disease activity.

    strongEvidence: very low/lowpharmacologic
  • rec_2

    Methotrexate monotherapy is strongly recommended over bDMARD or tsDMARD monotherapy.

    strongEvidence: very low/moderatepharmacologic

Glucocorticoids

  • rec_3

    Initiation of a csDMARD without longer-term (>=3 months) glucocorticoids is strongly recommended over initiation of a csDMARD with longer-term glucocorticoids.

    strongEvidence: moderatepharmacologic

DMARD-naive patients with low disease activity

  • rec_4

    Hydroxychloroquine is conditionally recommended over other csDMARDs.

    conditionalEvidence: very lowpharmacologic

Treatment modification

  • rec_5

    A treat-to-target approach is strongly recommended over usual care for patients who have not been previously treated with bDMARDs or tsDMARDs.

    strongEvidence: lowclinical approach

Tapering/discontinuing DMARDs

  • rec_6

    Continuation of all DMARDs at their current dose is conditionally recommended over a dose reduction of a DMARD.

    conditionalEvidence: lowpharmacologic

Scope & Objectives

Clinical Topic

Rheumatoid Arthritis

Objectives

To develop updated guidelines for the pharmacologic management of rheumatoid arthritis.

Target Patient Population

General rheumatoid arthritis patient population

Target Providers

CliniciansRheumatologists

Patient Criteria & Setting

Therapeutic Area

Immunology and Rheumatology

Guideline Scope

Pharmacologic management

Special Populations

Subcutaneous nodulesPulmonary diseaseHeart failureLymphoproliferative disorderHepatitis B infectionNonalcoholic fatty liver disease (NAFLD)Persistent hypogammaglobulinemia without infectionPrevious serious infectionNontuberculous mycobacterial (NTM) lung disease

Evidence Grading

System: GRADE

Evidence Levels

lowLow certainty in the effect estimate.
highHigh certainty that the true effect lies close to that of the estimate of the effect.
moderateModerate certainty in the effect estimate.
very_lowVery low certainty in the effect estimate.

Recommendation Strength

strongThe panel is highly confident that the recommended option favorably balances the expected benefits and risks for the majority of patients in clinical practice.
conditionalThe panel is less confident that the potential benefits outweigh the risks due to low/very low certainty in the evidence or an expectation of substantial variations in patient preferences.

Safety & Contraindications

Contraindications

  • TNF inhibitors should be avoided in patients with nontuberculous mycobacterial (NTM) lung disease.

Monitoring Guidance

For pretreatment screening and routine laboratory monitoring, readers are referred to the 2008, 2012, and 2015 guidelines.

Authors & Contributors

Liana FraenkelJoan M. BathonBryant R. EnglandE. William St.ClairThurayya ArayssiKristine CarandangKevin D. DeaneMark GenoveseKent Kwas HustonGail KerrJoel KremerMary C. NakamuraLinda A. RussellJasvinder A. SinghBenjamin J. SmithJeffrey A. SparksShilpa VenkatachalamMichael E. WeinblattMounir Al-GibbawiJoshua F. BakerKamil E. BarbourJennifer L. BartonLaura CappelliFatimah ChamseddineMichael GeorgeSindhu R. JohnsonLara KahaleBasil S. KaramAssem M. KhamisIris Navarro-MillánReza MirzaPascale SchwabNamrata SinghMarat TurgunbaevAmy S. TurnerSally YaacoubElie A. Akl

Guideline Features

Dosing informationBased on systematic reviewMultidisciplinaryPatient involvement

Learning Context

Difficulty

advanced

Learning Paths

Rheumatoid ArthritisDMARD TherapyTreat-to-TargetImmunologyPharmacologic Management