Rheumatoid Arthritis Treatment Guidelines

Initial Treatment

The recommended first-line treatment for rheumatoid arthritis is methotrexate (MTX) at 15-25 mg weekly, with the addition of low-dose glucocorticoids for initial disease control, followed by a treat-to-target approach with escalation to combination therapy or biologics if treatment targets are not met, as recommended by the European League Against Rheumatism (EULAR) 1, 2
Consider adding low-dose glucocorticoids (≤10 mg/day prednisone equivalent) for the first 3-6 months as bridging therapy, according to the American College of Rheumatology (ACR) and EULAR 1, 2
Leflunomide or sulfasalazine can be used as alternative first-line DMARDs, as suggested by EULAR and the ACR 1, 2, 4

Assess disease activity every 1-3 months in active disease, as recommended by EULAR 1
Aim for remission or low disease activity in all patients, with treatment adjustments made accordingly, as suggested by EULAR and the ACR 1, 4
If no improvement by 3 months or target not reached by 6 months, adjust therapy, according to EULAR and the ACR 1, 4

For patients with low/moderate disease activity without poor prognostic factors, consider adding hydroxychloroquine and sulfasalazine (triple therapy) or switching to subcutaneous MTX if oral MTX is ineffective, as suggested by the Mayo Clinic and EULAR 1, 3
For patients with high disease activity or poor prognostic factors, add a biologic DMARD (bDMARD) or targeted synthetic DMARD (tsDMARD), such as TNF inhibitors, abatacept, or IL-6 receptor antagonists, as recommended by EULAR and the ACR 1, 4

Switch to a different biologic agent with the same or different mechanism of action if treatment fails, as suggested by the Mayo Clinic and EULAR 1, 3, 4
For TNF inhibitor failures, consider switching to another TNF inhibitor, abatacept, tocilizumab, rituximab, or a JAK inhibitor, as recommended by the Mayo Clinic and EULAR 3, 4
Rituximab may be more effective in seropositive patients (RF+, anti-CCP+), while abatacept or tocilizumab may be preferred in seronegative patients who have failed TNF inhibitors, as suggested by the Mayo Clinic 3

Use caution with JAK inhibitors in patients with cardiovascular risk factors, as recommended by EULAR 4
Screen for tuberculosis, hepatitis B/C before starting biologics, and monitor for infections in patients on TNF inhibitors, although the specific citation for this is ignored

If sustained remission is achieved after tapering glucocorticoids, consider cautious tapering of biologics, as suggested by EULAR 4
Only consider tapering conventional DMARDs after long-term sustained remission, according to EULAR 4

Inadequate monitoring: Failure to assess response at 3-6 months may delay necessary treatment adjustments, as warned by EULAR and the ACR 1, 4
Premature switching: Allow adequate trial duration (3-6 months) before concluding treatment failure, as recommended by the Mayo Clinic 3
Neglecting treat-to-target approach: Failure to adjust therapy when targets aren't met leads to worse outcomes, as emphasized by EULAR and the ACR 1