HOD, Rheumatology, Manipal Hospital, Dwarka, New Delhi
Part 6 of 8 in Diagnosis and Management of Rheumatoid Arthritis
Treat-to-Target: The EULAR 2016 Recommendations and the DMARD Ladder
September 1, 2024
Dr. Ajmani framed treatment around the 2016 EULAR recommendations: DMARD therapy should be started as soon as the diagnosis of rheumatoid arthritis is made, aimed at reaching remission or low disease activity in every patient, with frequent, active monitoring every one to three months. If there is no improvement by three months, or the target hasn't been reached by six months, therapy should be adjusted.
The three classes of DMARDs
Conventional synthetic DMARDs include methotrexate (the most important first-line agent), hydroxychloroquine, leflunomide and sulfasalazine. Targeted synthetic DMARDs include JAK inhibitors such as tofacitinib. Biologic DMARDs split into anti-TNF agents, such as adalimumab and etanercept, and non-TNF biologics, such as rituximab (an anti-B cell agent) and the IL-6 pathway inhibitor tocilizumab.
The phased treatment algorithm
Methotrexate should be first-line unless contraindicated, for example in a patient planning pregnancy or with liver disease, in which case sulfasalazine is the safer choice (methotrexate and leflunomide are both unsafe in pregnancy and liver disease). Short-term glucocorticoids can bridge therapy while a DMARD takes effect, but should be tapered as rapidly as possible. If the target isn't met with the first conventional DMARD and there are no poor prognostic factors (male sex, joint erosions, deformities), switching to another conventional DMARD is reasonable; if poor prognostic factors are present, or a second conventional DMARD also fails, a biologic or JAK inhibitor should be added or substituted. If one biologic or targeted synthetic DMARD fails, switching to another, potentially with a different mechanism, is the next step.
This article is based on a Jivo Masterclass session conducted by Dr. Sajal Ajmani, HOD, Rheumatology, Manipal Hospital, Dwarka, New Delhi. The article has been summarised with the assistance of an AI tool from the original masterclass recording. Watch the full Masterclass recording
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This guide is based on a live Jivo Masterclass: Dr. Sajal Ajmani taught doctors across Africa on September 1, 2024.
FROM THE LIVE Q&A
Gadisa Dejene
What is the definition of sustained remission?
Dr. Sajal Ajmani
Sustained remission is defined as at least 12 months of remission before any therapy is decreased.
Frequently Asked Questions
Why does rheumatoid arthritis show a preferential pattern of joint involvement, and why are certain interphalangeal joints spared?▼
DIP (distal interphalangeal) joint involvement is less common in rheumatoid arthritis because there is less synovium in the DIP joints compared to the more commonly affected proximal interphalangeal and metacarpophalangeal joints.
What is the place of pulse or bolus intravenous corticosteroids (solumedrol) in an acute crisis of rheumatoid arthritis, generalised disabling joint pain with high fever?▼
Steroid pulse therapy can be given in severe RA in patients with many swollen and tender joints, usually methylprednisolone 500mg to 1000mg intravenously once a day for one to three days.
Beyond the joints, what organs can rheumatoid arthritis affect, particularly the heart, and how is that treated?▼
Extra-articular involvement is rare, but the lungs can develop interstitial lung disease, the eyes can develop scleritis and dryness, the heart very rarely can develop pericarditis and pericardial effusion, the kidneys very rarely can be affected by glomerulonephritis or amyloidosis, and the skin can develop vasculitis. For cardiac involvement specifically, treatment is steroids combined with methotrexate.
What is the recommended medical treatment for palindromic rheumatism?▼
Hydroxychloroquine.
What is the definition of sustained remission?▼
Sustained remission is defined as at least 12 months of remission before any therapy is decreased.
What is first-line treatment for rheumatoid arthritis?▼
Methotrexate, unless contraindicated (e.g. planned pregnancy or liver disease), in which case sulfasalazine is the safer alternative.
What are the three classes of DMARDs used in RA?▼
Conventional synthetic (methotrexate, hydroxychloroquine, leflunomide, sulfasalazine), targeted synthetic (JAK inhibitors like tofacitinib), and biologic (anti-TNF agents like adalimumab/etanercept, and non-TNF agents like rituximab and tocilizumab).
In This Series: Diagnosis and Management of Rheumatoid Arthritis
- 1.Diagnosis and Management of Rheumatoid Arthritis
- 2.Diagnosing Rheumatoid Arthritis: From the 1987 to the 2010 ACR/EULAR Criteria
- 3.Why Rheumatoid Factor and Anti-CCP Alone Don't Diagnose Rheumatoid Arthritis
- 4.Palindromic Rheumatism and Preclinical RA: Recognising Early and Atypical Presentations
- 5.Monitoring Disease Activity: DAS28, SDAI, CDAI and the ACR Response Criteria
- 6.Treat-to-Target: The EULAR 2016 Recommendations and the DMARD Ladder
- 7.Managing Severe Flares: Steroid Pulse Therapy and Achieving Sustained Remission
- 8.Extra-Articular Rheumatoid Arthritis: Lung, Eye, Heart, Kidney and Skin Involvement