Rheumatoid Arthritis

Set sustained remission as the preferred target; use low disease activity when remission is not realistically attainable. Early referral, early diagnosis, and early initiation of effective therapy followed by rapid adaptation when the target is missed are central to limiting progression of joint damage and preserving function.NatureNatureRheumatoid arthritis | Nature Reviews Disease Primers

Document the disease-activity measure used, the target, and the reassessment date before starting or changing therapy. A complete treat-to-target approach includes selecting a target and method to measure it, assessing at a prespecified time point, changing therapy if the target is not achieved, and shared decision-making; this strategy produces superior outcomes versus standard care.NatureNatureTreat-to-target in rheumatoid arthritis — are we there yet? | Nature Reviews Rheumatology

At each follow-up, distinguish active inflammatory disease from a noninflammatory source of pain or functional limitation before escalating immunomodulation. When measurable disease activity remains above the agreed target, change the DMARD strategy rather than continuing an ineffective regimen without a defined endpoint.Nature+1NatureTreat-to-target in rheumatoid arthritis — are we there yet? | Nature Reviews RheumatologyNatureRheumatoid arthritis | Nature Reviews Disease Primers

Methotrexate is the principal conventional DMARD anchor in contemporary rheumatoid arthritis treatment strategies. Conventional DMARD options considered in ACR treatment recommendations include methotrexate, hydroxychloroquine, leflunomide, sulfasalazine, and, less commonly, minocycline; combination regimens using two or three conventional DMARDs are also recognized treatment approaches.WileyWiley2012 Update of the 2008 American College of Rheumatology recommendations for the use of disease‐modifying antirheumatic drugs and biologic agents in the treatment of rheumatoid arthritis<link href='#fn1'></link><link href='#fn2'></link><link href='#fn3'></link><link href='#fn4'></link>

When methotrexate cannot be used, select leflunomide or sulfasalazine as part of the first treatment strategy rather than delaying DMARD treatment.WileyWileySummary of the new EULAR rheumatoid arthritis guideline If methotrexate is used, actively elicit gastrointestinal intolerance and monitor for liver dysfunction, pneumonitis, and bone marrow toxicity, which are recognized adverse effects that can require regimen modification.WileyWileyDiagnosis and management of rheumatoid arthritis

For persistent active disease despite an adequate methotrexate-based strategy, choose between combination conventional DMARD therapy and an advanced DMARD approach based on disease activity, prior exposure, contraindications, and preference. In a randomized trial of active RA after methotrexate failure, triple conventional therapy and etanercept plus methotrexate were compared; sulfasalazine could be reduced to 500 mg twice daily for unacceptable adverse effects, illustrating a tolerability-based adjustment within combination treatment.NEJMNEJMTherapies for Active Rheumatoid Arthritis after ...

Before prescribing a JAK inhibitor, document prior major adverse cardiovascular events and major cardiovascular risk factors, including current cigarette smoking, hypertension, hypercholesterolemia, diabetes mellitus, family history of premature coronary disease, and established coronary artery disease. ORAL Surveillance enrolled methotrexate-inadequate responders aged 50 years or older with at least one additional cardiovascular risk factor, making this phenotype particularly important when translating the safety signal to practice.BMJBMJWaiting for JAK inhibitor safety data | RMD Open

In rheumatoid arthritis and other immune-mediated inflammatory diseases, JAK inhibitors are associated with serious infection rates similar to biologic DMARDs but with increased herpes zoster rates compared with biologic DMARDs. Reducing or eliminating concomitant glucocorticoid exposure can lower infectious-event risk.BMJBMJmediated inflammatory diseases with Janus kinase inhibitors

Do not treat JAK inhibitors as interchangeable with other advanced DMARDs in patients with elevated baseline cardiovascular or malignancy risk. Regulatory cautions were prompted by increased cardiovascular and malignancy events with tofacitinib in older RA patients with cardiovascular risk factors; when a JAK inhibitor remains the preferred option, mitigate modifiable cardiovascular risk and reassess the risk-benefit balance at each treatment change.BMJ+1BMJWaiting for JAK inhibitor safety data | RMD OpenBMJEULAR recommendations for the management of psoriatic ...

At every planned assessment, record disease activity relative to the predefined target, treatment adherence, toxicities, and new comorbidities that alter advanced-DMARD safety. Continue the regimen only when disease control and tolerability support the original treatment goal; otherwise optimize or switch therapy according to the escape plan established at treatment initiation.Nature+1NatureTreat-to-target in rheumatoid arthritis — are we there yet? | Nature Reviews RheumatologyNatureRheumatoid arthritis | Nature Reviews Disease Primers

For methotrexate-based treatment, investigate new gastrointestinal symptoms and clinically suspected liver, pulmonary, or bone marrow toxicity rather than attributing symptoms automatically to RA activity.WileyWileyDiagnosis and management of rheumatoid arthritis For JAK inhibitors, review infectious events, herpes zoster, cytopenias, thromboembolic events, and evolving cardiovascular risk before refilling or escalating therapy.BMJ+2BMJmediated inflammatory diseases with Janus kinase inhibitorsBMJWaiting for JAK inhibitor safety data | RMD OpenBMJEULAR recommendations for the management of psoriatic ...

Patients who have failed multiple biologic DMARDs represent a difficult-to-treat subgroup in whom additional targeted options may retain efficacy, including JAK inhibitors; however, risk assessment remains decisive because efficacy does not negate cardiovascular, malignancy, infection, or thrombosis concerns.BMJ+3BMJTherapeutic approaches for difficult-to-treat rheumatoid ...BMJmediated inflammatory diseases with Janus kinase inhibitorsBMJWaiting for JAK inhibitor safety data | RMD OpenBMJEULAR recommendations for the management of psoriatic ...