2021 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis
(Part 4)
We now continue with our discussion on the guidelines for the Treatment of Rheumatoid Arthritis as presented by the American College of Rheumatology (ACR).
Disease Modifying Antirheumatic Drugs (DMARD) monotherapy such as the use of the drug methotrexate is strongly recommended over hydroxychloroquine or sulfasalazine for certain patients with moderate-to-high disease activity.
The ACR recommends methotrexate due to very low-certainty evidence for hydroxychloroquine and low-certainty evidence for sulfasalazine based on the amount of data obtained in studies.
Methotrexate is conditionally recommended over leflunomide for certain patients especially those with moderate-to-high disease activity.
Methotrexate is chosen over leflunomide because the data present the former’s value as an anchor DMARD used in combination with other treatments. Methotrexate is also cheaper compared to other drugs.
We need to consider that there is some evidence showing the superiority of the drug tocilizumab over methotrexate and Janus kinase (JAK) inhibitor.
A study says that methotrexate is chosen due to its established efficacy and safety as a first-line DMARD and affordablecost.
Moreover, tocilizumab and JAK inhibitors are not approved by the US Food and Drug Administration (FDA) for some patients.
There are some safety concerns linked with JAK inhibitors, which pushed expets in the ACR to push for the use of methotrexate for certain patients.
Methotrexate is recommended over dual or triple conventional synthetic DMARD therapy for certain patients with moderate-to-high disease activity.
The recommendation goes towards the favor of methotrexate because of the cost.
However, some patients may choose csDMARD combination therapy for an increased probability of obtaining a better response despite the added costs of taking multiple drugs.
Methotrexate monotherapy is sightly better than methotrexate plus a tumor necrosis factor (TNF) inhibitor for certain patients with moderate-to-high disease activity.
Methotrexate use alone is better because of toxicity issues and higher trearment costs. Although some patients who want rapid results may benefit and greater chance of improvement that can be obtained with the use of combination therapy.
Methotrexate monotherapy is strongly recommended over methotrexate plus a non–TNF inhibitor bDMARD or tsDMARD for DMARD-naive patients with moderate-to-high disease activity.
The use of glucocorticoids is conditionally recommended over the use of a csDMARD for certain patients with moderate-to-high disease activity.
The experts agreed that glucocorticoids should not be systematically prescribed.
The use of glucocorticoids needs to be limited to the lowest effective dose and the treatment should not be prolonged.The toxicity linked with glucocorticoids use was seen to outweigh potential benefits.
Although some patients may require longer-term glucocorticoids, this strong recommendation against longer-term glucocorticoid usr is made because of its significant toxicity.
We will continue our discussion on the different treatment regimens for the treatment of rheumatoid arthritis next week.