Management of Rheumatoid Arthritis in Patients with Gastric Ulcer

DMARD Initiation and Escalation

Initiate methotrexate immediately as the first‑line conventional DMARD, even when a gastric ulcer is present, because conventional DMARDs do not increase the risk of gastric mucosal injury【1】【2】.
Use an adequate methotrexate dose (oral or sub‑cutaneous) together with folic‑acid supplementation to achieve disease control【1】.
If methotrexate is contraindicated or not tolerated, substitute leflunomide or sulfasalazine as alternative first‑line csDMARDs【1】【2】.
Escalate to a biologic DMARD (e.g., TNF‑α inhibitor, IL‑6 inhibitor) or a JAK inhibitor when the response is inadequate after 3 months or the therapeutic target is not reached by 6 months, especially in patients with poor prognostic factors【1】【2】.

Reduce corticosteroid doses to the lowest possible level or discontinue them; glucocorticoids should be used only as short‑term bridging therapy while DMARDs are being up‑titrated, not for long‑term maintenance【1】【2】.

Provide mandatory high‑dose proton‑pump‑inhibitor (PPI) therapy for all patients, as PPIs are the most effective strategy to prevent gastric mucosal damage in this population【1】【2】.

For DMARD‑naïve patients with a gastric ulcer, start methotrexate (plus short‑term glucocorticoids only if absolutely necessary) together with mandatory PPI coverage【1】【2】.
Monitor disease activity every 1–3 months to assess response【2】.
If disease activity remains inadequate at 3 months or the target is not achieved by 6 months, add a biologic DMARD (TNF inhibitor, IL‑6 inhibitor, etc.) or a JAK inhibitor【1】【2】.
The therapeutic goal is sustained remission or low disease activity; achieving this target through aggressive DMARD therapy eliminates the need for ongoing NSAIDs and high‑dose corticosteroids【1】【2】.
Once remission is maintained, consider cautious tapering of DMARDs while continuing gastro‑protective PPI therapy【2】.

Poor prognostic factors include high rheumatoid factor/anti‑CCP antibody levels, high disease activity, early radiographic joint damage, or failure of two conventional DMARDs【2】.
In patients exhibiting these factors, consider adding a biologic DMARD or JAK inhibitor earlier than the standard 6‑month window to achieve faster disease control and reduce exposure to NSAIDs and corticosteroids【2】.