Rheumatoid Arthritis and Juvenile Idiopathic Arthritis Treatment Guidelines

Initial Treatment Strategy

The American College of Rheumatology recommends methotrexate as the first-line DMARD for most patients with rheumatoid arthritis, rapidly escalated to 20-25 mg weekly, combined with short-term low-dose glucocorticoids as bridging therapy 1
For patients with moderate or high disease activity, add low-dose glucocorticoids (≤10 mg/day prednisone equivalent) when starting DMARDs 1, 2
Limit glucocorticoid duration to less than 3 months and taper as rapidly as clinically feasible to minimize long-term adverse effects 1

Monitor disease activity every 1-3 months using validated measures (SDAI, CDAI, or DAS28) with a treatment target of remission or low disease activity 1
If methotrexate monotherapy fails after 3 months in patients with moderate-to-high disease activity, add a biologic DMARD (preferably a TNF inhibitor) or targeted synthetic DMARD in combination with methotrexate 1
TNF inhibitors (adalimumab, etanercept, infliximab, golimumab, certolizumab pegol) are the preferred first biologic agents 1

Intra-articular corticosteroids serve as adjunctive therapy for mono- or oligoarthritis, not primary treatment 2
Use intra-articular corticosteroids as bridging therapy while awaiting DMARD efficacy 2
Consider intra-articular corticosteroids for persistent synovitis in specific joints despite adequate systemic therapy 2

For patients with heart failure (NYHA class III or IV), use non-TNF inhibitor biologics or targeted synthetic DMARDs instead of TNF inhibitors, as TNF inhibitors can worsen heart failure 1
Perform tuberculosis screening (TST or IGRA) before initiating biologics or JAK inhibitors 1
Perform hepatitis B and C screening before initiating biologics 1
For patients with hepatitis B infection, prophylactic antiviral therapy is strongly recommended for those initiating rituximab who are hepatitis B core antibody positive 1

For oligoarticular JIA, a trial of scheduled NSAIDs combined with intra-articular glucocorticoids is recommended as initial therapy, with triamcinolone hexacetonide as the preferred steroid agent 3, 4
Conventional synthetic DMARDs are strongly recommended if there is inadequate response to scheduled NSAIDs and/or IAGCs, with methotrexate as the preferred agent 3, 4
Biologic DMARDs are strongly recommended if there is inadequate response to or intolerance of NSAIDs and/or IAGCs and at least 1 conventional synthetic DMARD 3, 4

For patients aged ≥75 years, topical NSAIDs are strongly recommended over oral NSAIDs due to reduced gastrointestinal risk 6

Both selective (etoricoxib) and nonselective (piroxicam) NSAIDs carry cardiovascular risks proportional to COX-2 selectivity and the patient's underlying cardiovascular risk 6
Use NSAIDs at the minimum effective dose for the shortest time possible after evaluation of gastrointestinal, renal, and cardiovascular risks 6
For patients with history of symptomatic or complicated upper GI ulcer, a COX-2 selective inhibitor is strongly recommended over nonselective NSAIDs 6
Neither etoricoxib nor piroxicam should be used in patients with chronic kidney disease stage IV or V (eGFR <30 ml/min) 6
Regular monitoring of blood pressure, renal function, and liver function is recommended for patients on long-term NSAID therapy 6

For patients in sustained remission (at least 6 months of low disease activity or remission), consider cautious de-escalation of therapy through shared decision-making 1
Approximately 15-25% of patients may achieve sustained drug-free remission, particularly those with shorter symptom duration, absence of rheumatoid factor or anti-CCP antibodies, lower disease activity before remission, and less baseline disability 1