Rheumatoid arthritis: new EULAR treatment guidelines

Several new developments have led to changes in the EULAR recommendations to treat rheumatoid arthritis. They include the use of JAK inhibitors, short-term corticosteroid administration, and treatment tapering.

The new EULAR guidelines on the management of rheumatoid arthritis (RA) were presented by Prof. Daniel Aletaha (Medical University Vienna, Austria) [1,2]. His presentation covered the following topics: treat-to-target and remission, precision medicine, expanding therapeutic opportunities, glucocorticoids, and possible treatment reduction decisions [1].

The treat-to-target approach has been widely implemented among rheumatologists for about 10 years. Remission criteria are not new, but recently, there has been some discussion on the role of Patient Global Assessment (PGA) within the Boolean criteria. There is ongoing research about the use of increasing the cut-off point for the PGA to improve the consistency of the Boolean criteria with the Simple Disease Activity Index (SDAI) criteria.

Regarding precision medicine, Prof. Aletaha indicated that, currently, there are no single or combined markers that drive treatment guidance for RA patients at baseline to tailor biologic treatment. “The problem is that often only one therapy is investigated based on clinical trials that are analysed. Often we only look at “-omics” and we should be thinking about a broader context, maybe going to socio-demographics and age, or other factors that –combined with biological data– can create a biotype that can then be used to try and predict a phenotype. These markers will then give you the precision-medicine approach,” Prof. Aletaha elaborated. Hence, the challenges of precision medicine might be partly due to the heterogeneity of outcome and the lack of phenotypes of response. 

JAK Inhibitors: a novel addition in the guidelines

The EULAR recommendations newly implemented JAK inhibitors on the same level as biologic DMARDs after failure of methotrexate (see Figure). Concerning small molecules, Prof. Aletaha recapitulated that the targeted synthetics approach various targets while biologics are highly efficient for one specific target and may indirectly target others.

Figure. New position of JAK inhibition in the EULAR 2020 recommendations [2]



RF, rheumatoid factor; ACPA, anticitrullinated protein antibody; DMARDs, disease-modifying antirheumatic drugs; csDMARDs, conventional synthetic DMARDs; bDMARD, biologic DMARD.

As for glucocorticoids: they should be combined short term with conventional DMARDs. This is partly based on outcomes from the IDEA study [3]. In IDEA, methotrexate plus infliximab had no statistically significant superiority over methotrexate plus high-dose corticosteroids in DMARD-naïve early RA patients. Furthermore, the NORD-STAR trial (NCT01491815) assessed aggressive conventional therapy including corticosteroids and the results showed that it had relative non-inferiority compared with other treatments like biologics [4].

The last subject covered was medication tapering for patients who reached their treatment target recommended by the current EULAR algorithm [1]. “The most important question when we want to taper off patients on biological DMARDs is: which predictors are indicating successful discontinuation,“ said Prof. Aletaha. He indicated that these include low disease activity, better physical function, absence or low presence of rheumatoid factor (RF) or anticitrullinated protein antibody (ACPA), low levels of C-reactive protein (CRP), shorter disease duration, and low signals of disease activity by ultrasound.

1. Aletaha D. In 2020, what recent data guide treatment decisions in rheumatoid arthritis? 4S005, ACR Convergence 2020, 5-9 Nov.
2. Smolen JS, et al. Ann Rheum Dis. 2020;79:685-99.
3. Nam JL, et al. Ann Rheum Dis. 2014;73:75-85.
4. Hetland ML, et al. L09, 2019 ACR/ARP Annual Meeting.

Posted on 18 January 202118 January 2021