Rheumatoid Arthritis

Publication Date: November 6, 2015

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.
NOTE: All numeric superscripts refer to Source References. Alphabetic superscripts refer to footnotes at the end of figures and tables.

Table 1. Definitions

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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.
New classification criteria for aRA (ACR /EULAR3 collaborative initiative) were published in 2010. The definition of established RA is based on the 1987 ACRRA2 Classification criteria, since the 2010 ACRRA classification allows a much earlier diagnosis.
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 RAHaving trouble vie...

Assessment

...essment

...ruments to Measure Rheumatoid Arthritis Disease A...


Treatment

...reatme...

...4. Recommendations for Patients with Symptomatic E...

1. Regardless of disease activity level, us...

...MARD monotherapy (MTX preferred) ove...

...e DMARD monotherapy (MTX preferred) ov...

...se DMARD monotherapy over double the...

...monotherapy over triple therapy. (Con...

...activity remains moderate or high...

...i monotherapy over tofacitinib monot...

...X over tofacitinib MTX. (Conditional, L...

...ARD or (Conditional, Mode...

...gic therapies, (Conditional, Low)578...

...ares, add short-term glucocorticoids...


...1. Early Rheumatoid Arthritis...


...commendations for Patients with Establish...

...of disease activity level, use a treat-to...

...disease activity is low, in patients...

...monotherapy (MTX preferred) over tofacitinib....

...RD monotherapy (MTX preferred) over combination...

...f disease activity remains moderate or high despi...

...If disease activity remains moderate or...

...iologic, with or without methotrexate, over anoth...

...a non-TNF biologic, with or without methot...

.... If disease activity remains moderate or...

...If disease activity remains moderate or hig...

...ase activity still remains moderate or hig...

...t use another non-TNF biologic, wit...

...ase activity remains moderate or hi...

...activity remains moderate or high despi...

...2. If disease flares in patients on DMARD,...

...therapy. (Conditional, Low)Lowd578...

...TNFi, non-TNF biologic, or tofacitinib (please...

...ARD therapy. (Strong, Moderate)578...

...inue TNFi, non-TNF biologic or tofacitinib rath...

...the patient’s disease is in remiss...

...finition of established aRA is based on...


...gure 2. Established Rheumatoid Art...


Table 6. Laboratory Monitoring for RA P...


...le 7. Recommendations for High-Risk Patients with...

...ve heart failure (CHF)a...

CHFUse combination DMARDs or non-TNF...

...orsening on current TNFi therapyUse...

...titis Bc...

...itis B infection and receiving/received...

...atitis Cc...

...infection and receiving/received effective anti...

...itis C infection and not receiving or requiri...

...treated or untreated malignancye...

...ed or untreated skin cancer (non-melanom...

...ted lymphoproliferative disorderUse rituximab...

...iously treated lymphoproliferative disorde...

...ted solid organ malignancySame recommenda...

...evious Serious Infection(s)f

...s Serious infection(s)Use combination DM...

...ecommendations supported by evidence level...


Screening/Preventive Therapy

...creening/Preventive Thera...

...le 8. Use of Vaccines in Patients with Rheumatoi...


...culosis (TB) Screening Algorithm fo...



References

...References Anderson J, Caplan L, Yazda...