2021 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis
(Part 5)
Let’s continue our discussion on the recommendations of the American College of Rheumatology all biologic Disease Modifying Anti-Rheumatism Drugs (bDMARDs) and targeted systemic DMARD (tsDMARD) by starting the topic with methotrexate therapy.
Methotrexate monotherapy is conditionally recommended over the combination of methotrexate plus a bDMARD or tsDMARD.
The recommendation is considered to be conditional as the experts see that some patients who have had persistent disease activity despite use of 1 or more conventional synthetic (csDMARD) will prefer combination medication for a faster outcome.
Oral methotrexate is conditionally recommended over subcutaneous methotrexate for certain patients, experts say.
Oral administration is better, despite some pieces of evidence saying that subcutaneous injections may have better efficacy, as oral administration is easier.
The use of methotrexate to a weekly dose of at least 15 mg within 4 to 6 weeks is better in certain conditions over the use of the said drug using a weekly dose of <15 mg.
This particular recommendation is considered as conditional as some studies show the trade off between the improved efficacy and toxicity risks linked with increased starting doses.
This particular recommendation is good only to the initial use of methotrexate and is not meant to limit further dose increase, which often provides better outcomes.
The split dose of oral methotrexate over 24 hours or weekly subcutaneous injections, and/or an increased dose of folic/folinic acid, may be used based on certain conditions over to using DMARD for patients not tolerating oral weekly methotrexate.
The split dosing and increased doses of folic/folinic acid are the better initial strategies over switching to another DMARD because of the efficacy, long-term safety, and low costs.
The patient preferences, in scenario, play an important role in the decision whether to continue methotrexate or switch to other DMARDs.
Moving to subcutaneous methotrexate is recommended for certain conditions over the addition of/switching to alternative DMARD.
This recommendation is consistent with the expert’s principle of maximizing use of methotrexate prior to switching.
However, there is no data showing the results in patients who switch to subcutaneous methotrexate versus another treatment strategy that includes other DMARDs.
The recommendation is allowed in certain conditions because patient choices and the past response to methotrexate play an important role in this decision.
Next week we will shift our focus to the treat-to-target approach in the treatment modalities in treating Rheumatoid Arthritis.