Rheumatoid Arthritis
Key Points
Key Points
- Focus on common clinical scenarios, not exceptional cases
- Cost is a consideration in these recommendations. However, explicit cost-effectiveness analyses were not conducted.
- Disease activity measurement using an ACR-recommended measure should be performed in a majority of encounters with patients with rheumatoid arthritis (RA1).
- Functional status assessment using a standardized, validated measure should be performed routinely for RA patients, at least once per year, but more frequently if disease is active. Examples of commonly used functional status measures include Health Assessment Questionnaire (HAQ), Health Assessment Questionnaire-II (HAQ-II), Multidimensional Health Assessment Questionnaire (MD-HAQ), Patient-Reported Outcomes Measurement Information System , Physical Function 10-item, PROMIS Physical Function 20-item, and PROMIS Physical Function Computerized Adaptive Tests (PROPFCAT).
- If a patient has low RA disease activity or is in clinical remission, switching from one therapy to another should be considered only at the discretion of the treating physician in consultation with the patient.
Arbitrary switching between RA therapies based only on a payer/insurance company policy is not recommended. - A treatment recommendation favoring one medication over another means that the preferred medication would be the recommended first option. However, favoring one medication over the other does not imply that the non-favored medication is contraindicated for use in that situation; it may still be a potential option under certain conditions.
Table 1. Definitions
Key Terms and Definitions
- Adult RA patient
- Adults, 18 years and older, meeting the ACRRA2, 3 classification criteria.
- Health Benefits and Harms
- Efficacy and safety of treatments including desirable and undesirable effects.
- Early RA
- RA with duration of disease/symptoms of <6 months, where “duration” denotes the length of time the patient has had symptoms/disease, not the length of time since RA diagnosis.
- Established RA
- RA with duration of disease/symptoms of ≥6 months OR meeting 1987 ACRRAa classification criteria.
- Disease activity
- Categorized as low, moderate, or high as per validated scales
(Table 3). Moderate and high disease activity categories were combined, as used previously for the 2012 ACRRA1 treatment recommendations.
- RA remission
- A joint ACR-EULAR task force defined remission as a tender joint count, swollen joint count, C-reactive protein (mg/dL) and patient global assessment ≤1 each or a Simplified Disease Activity Score (DAS4) of ≤ 3.3, one of 6 ACR-endorsed disease activity measures.b
- Optimal dosing of RA treatments
-
- Dosing to achieve a therapeutic target derived from mutual patient-clinician consideration of patient priorities, and
- Given for ≥3 months before therapy escalation or switching.
- DMARD failure
- Failure of traditional/conventional DMARD(s) due to lack of efficacy/desired response or side effects.
- Biologic failure
- Failure of biologic(s) due to lack of efficacy/desired response or side effects.
- Secondary biologic failure
- A biologic was efficacious initially but subsequently became inefficacious.
- Active hepatitis B infection
- Hepatitis B surface antigen positive, Hepatitis B surface antibody negative, Hepatitis B core antibody total positive (less important), AST/ALT typically increased, HBV DNA positive (if checked).
- Hepatitis C infection
- HCV antibody positive, HCV RNA positive, AST/ALT typically increased.
- NYHA class III and IV
-
- NYHA class III includes patients with cardiac disease resulting in marked limitation of physical activity with less than ordinary physical activity causing fatigue, palpitation, dyspnea, or angina, but no symptoms at rest.
- NYHA5 class IV includes patients with cardiac disease resulting in inability to carry on any physical activity without discomfort, symptoms of heart failure are present even at rest, and discomfort increases if any physical activity is undertaken.
b Any of the ACR-recommended disease activity measures may be chosen, as described in Anderson et al.1
Table 2. Agents Used in Treating RA
...ents Used in Treating RAHaving trouble vie...
Assessment
...Assessment...
...3. Instruments to Measure Rheumatoid...
Treatment
...Treatment...
...Tabl...
...Regardless of disease activity level,...
...D monotherapy (MTX preferred) over...
...onotherapy (MTX preferred) over trip...
use DMARD monotherapy over double therapy. (Con...
...ARD monotherapy over triple therapy...
...ase activity remains moderate or high desp...
...a TNFi monotherapy over tofacitinib mono...
...e a TNFiMTX over tofacitinib MTX. (C...
...RD or (Conditional, Moderate)578
...therapies, (Conditional, Low)578...
...sease flares, add short-term glucocorticoids a...
...arly Rheumatoid Arthritis...
...Table 5. Recomme...
...disease activity level, use a treat-to...
...disease activity is low, in patients who have nev...
...monotherapy (MTX preferred) over tofacitinib. (Co...
...onotherapy (MTX preferred) over combination DMA...
...ctivity remains moderate or high despite...
...e activity remains moderate or high despi...
...se a non-TNF biologic, with or without metho...
...on-TNF biologic, with or without meth...
...tivity remains moderate or high despite use o...
...f disease activity remains moderate o...
...ase activity still remains moderate or high despi...
...use another non-TNF biologic, with o...
If disease activity remains moderate or high,...
...sease activity remains moderate or high despite...
...If disease flares in patients on DMAR...
...MARD therapy. (Conditional, Low)Lowd578...
...-TNF biologic, or tofacitinib (please al...
...therapy. (Strong, Moderate)578...
...Fi, non-TNF biologic or tofacitinib rath...
15. If the patient’s disease is in remi...
...efinition of established aRA is base...
...2. Established Rheumatoid Arthritis2...
...boratory Monitoring for RA Patients on DMARDs: R...
...Table 7. Recommendat...
...Conges...
...combination DMARDs or non-TNF biologic...
...n current TNFi therapyUse combination DMARDs o...
...Hepati...
...epatitis B infection and receiving/rece...
...Hepatitis...
...is C infection and receiving/received eff...
...C infection and not receiving or r...
...Past history o...
...ted or untreated skin cancer (non-me...
...reated lymphoproliferative disorderUse r...
...reated lymphoproliferative disorderUse combinatio...
...usly treated solid organ malignancySame recom...
...Previous Serious In...
...infection(s)Use combination DMARD o...
...al recommendations supported by evidence...
Screening/Preventive Therapy
...Screening/Pr...
...Vaccines in Patients with Rheumatoid Arthritis...
...ulosis (TB) Screening Algorithm for Biolog...
References
...ces Anderson J, Caplan L, Yazdany...