New guidelines for treatment of rheumatoid arthritis

Abstract

In 2017, the Czech Rheumatology Society issued the revised Guidelines for the Treatment of Rheumatoid Arthritis (RA). Their mainstay is timely diagnosis of the disease and immediate initiation of effective treatment. Treatment strategy is guided by assessment of disease activity using composite indexes at regular time intervals and by medication adjustment in the case of failure to achieve the treatment goal. Usually by the third month of treatment initiation, it is recommended to achieve at least a 50% reduction in the activity and, by the sixth month, the treatment goal, i.e. remission (alternatively low clinical activity). It is advised to initiate monotherapy with methotrexate; when contraindicated or intolerated, the use of leflunomide or sulfasalazine should be considered. In most cases, it is recommended to consider glucocorticoids at the onset of the disease (sometimes also in the case of relapse of established RA); in addition to low doses, medium and/or high doses are acceptable. The duration of glucocorticoid administration should ideally be less than three months, certainly not longer than six months. If there is failure of the initial treatment strategy, the further steps are governed by the presence of adverse prognostic factors (high disease activity, positive autoantibodies, and early erosive joint damage). If they are absent, a switch to another conventional synthetic disease-modifying antirheumatic drug and/or their combination can be considered. In patients with adverse prognostic factors, it is appropriate to consider the addition of biological therapy (TNF inhibitors, abatacept, tocilizumab or sarilumab, and, under certain circumstances, even rituximab) or the use of a targeted synthetic drug (Janus kinase inhibitors). Biosimilar drugs are thought to be equal to reference original biological drugs. In patients with sustained remission (with a duration of at least six months) who are no longer treated with glucocorticoids, it is possible to consider a dose reduction of the biological drug or prolongation of the administration interval. Complete withdrawal of the biological drug often results in a flare-up of the disease. The Guidelines provide practicalguidance on how to proceed with treatment of patients with RA in the majority of cases.