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
...Agents Used in Treating RADrug Categ...
Assessment
...Assessment...
Table 3. Instruments to Measure Rh...
Treatment
...Treatment...
...Table 4. R...
...ardless of disease activity level, use a t...
use DMARD monotherapy (MTX preferred) ov...
...monotherapy (MTX preferred) over triple therap...
...MARD monotherapy over double therapy. (Condition...
...notherapy over triple therapy. (Conditio...
...disease activity remains moderate or high de...
...herapy over tofacitinib monotherapy....
...over tofacitinib MTX. (Conditional, Lo...
...D or (Conditional, Moderat...
...erapies, (Conditional, Low)578...
...ease flares, add short-term glucocorti...
...Early Rheumatoid Arthritis...
...Table 5. Recommendations f...
...rdless of disease activity level, use a treat...
....If the disease activity is low, in patients who h...
...therapy (MTX preferred) over tofacitinib. (Condit...
...D monotherapy (MTX preferred) over combina...
...If disease activity remains moderate o...
...f disease activity remains moderate or high desp...
...non-TNF biologic, with or without meth...
...F biologic, with or without methotrexa...
...If disease activity remains moderate...
...se activity remains moderate or hig...
.... If the disease activity still rem...
...another non-TNF biologic, with or wit...
...vity remains moderate or high, use tofacitinib...
...If disease activity remains moderate or...
...flares in patients on DMARD, TNFi, or no...
...perc DMARD therapy. (Conditional,...
...per TNFi, non-TNF biologic, or tofac...
...ue DMARD therapy. (Strong, Modera...
...e TNFi, non-TNF biologic or tofacitinib...
.... If the patient’s disease is in remission,...
...n of established aRA is based on the...
...2. Established Rheumatoid Arthr...
...6. Laboratory Monitoring for RA Patien...
...Congestive heart fa...
...tion DMARDs or non-TNF biologic or tofac...
...ng on current TNFi therapyUse combin...
...Hepatitis Bc...
...ive Hepatitis B infection and receiving/rec...
...is C infection and receiving/received effective a...
...s C infection and not receiving or requirin...
...Past histo...
...ated or untreated skin cancer (non-melanoma or mel...
Previously treated lymphoproliferative dis...
...ated lymphoproliferative disorderUse co...
...ated solid organ malignancySame recommendations as...
...Previous Se...
...revious Serious infection(s)Use combinat...
...al recommendations supported by evidence level r...
Screening/Preventive Therapy
...Screening/Preventive T...
...able 8. Use of Vaccines in Patients with Rheumatoi...
...3. Tuberculosis (TB) Screening Algorit...
References
...eferences Anderson J, Caplan L, Yazdany J...