The European League Against Rheumatism (EULAR) recently released its 2025 update (published in March 2026) to its guideline, Management of Rheumatoid Arthritis with Synthetic and Biologic Disease-Modifying Antirheumatic Drugs (DMADs). Every three years, EULAR updates the guideline, which is primarily aimed at health care professionals who handle DMAD therapy for patients with rheumatoid arthritis, based on the latest available evidence.
While no new drug approvals occurred between this update and the previous 2022 update, some recommendations have been adjusted based on the results of several trials. Below we have a look at the recommendations from the 2022 guideline alongside the latest, 2026 version.
Guidelines Referenced:
EULAR Recommendations for the Management of Rheumatoid Arthritis with Synthetic and Biologic Disease-Modifying Antirheumatic Drugs: 2025 Update
EULAR Recommendations for the Management of Rheumatoid Arthritis with Synthetic and Biological Disease-Modifying Antirheumatic Drugs: 2022 Update
- Publication: January 2023
- Full Text
EULAR Recommendations for the Management of Rheumatoid Arthritis with Synthetic and Biologic DMADs (2022–2026)
The following table compares the updated recommendations added in the 2025 update to the previous 2022 versions. To view the most thorough version of the recommendations, along with the overall overarching principals, view the full-text versions using the links featured above.
| Topic | 2022 | 2026 |
|---|---|---|
| Therapy with DMARDs | Therapy with DMARDs should be started as soon as the diagnosis of RA is made. | Therapy with DMARDs should be started as soon as the diagnosis of RA is made. |
| Treatment Aims | Treatment should be aimed at reaching a target of sustained remission or low disease activity in every patient. | Treatment should be aimed at reaching a target of sustained remission or low disease activity in every patient. |
| Monitoring | Monitoring should be frequent in active disease (every 1–3 months); if there is no improvement by at most 3 months after the start of treatment or the target has not been reached by 6 months, therapy should be adjusted. | Disease activity monitoring should be frequent in active disease (every 1-3 months); if there is no improvement by at most 3 months after the start of treatment or the target has not been reached by 6 months, therapy should be adjusted; when the target is sustained, monitoring can be less frequent. |
| Methotrexate (MTX) | MTX should be part of the first treatment strategy. In patients with a contraindication to MTX (or early intolerance), leflunomide or sulfasalazine should be considered as part of the (first) treatment strategy. | MTX should be part of the first treatment strategy; in patients with a contraindication to MTX (or early intolerance), leflunomide or sulfasalazine should be considered. |
| Short-Term Glucocorticoids (GCs) | Short-term GCs should be considered when initiating or changing csDMARDs, in different dose regimens and routes of administration, but should be tapered and discontinued as rapidly as clinically feasible. | Short-term GCs should be considered when initiating or changing csDMARDs, in different dose regimens and routes of administration, but should be tapered and discontinued as rapidly as clinically feasible. |
| Treatment Targets | If the treatment target is not achieved with the first csDMARD strategy, in the absence of poor prognostic factors, other csDMARDs should be considered. If the treatment target is not achieved with the first csDMARD strategy, when poor prognostic factors are present, a bDMARD should be added; JAK-inhibitors may be also considered, but pertinent risk factors must be taken into account. | If the treatment target is not achieved with the csDMARD strategy, a bDMARD should be added; JAK inhibitors may be considered, but pertinent risk factors must be taken into account. |
| Biological DMARDs Combined with Conventional Synthetic DMARDs | bDMARDs and tsDMARDs should be combined with a csDMARD; in patients who cannot use csDMARDs as comedication, IL-6 pathway inhibitors and tsDMARDs may have some advantages compared with other bDMARDs. | bDMARDs/tsDMARDs should be combined with a csDMARD; in patients who cannot use csDMARDs as comedication, IL-6 pathway inhibitors and JAK inhibitors may have some advantages compared with other bDMARDs. |
| bDMARD/tsDMARD Failure | If a bDMARD or tsDMARD has failed, treatment with another bDMARD or a tsDMARD should be considered; if one TNF- or IL-6 receptor inhibitor therapy has failed, patients may receive an agent with another mode of action or a second TNF- or IL-6 receptor inhibitor. | If a bDMARD or tsDMARD has failed, treatment with another bDMARD or a tsDMARD should be considered; if 1 TNF or IL-6 receptor inhibitor therapy has failed, patients may receive an agent with another mode of action or a second TNF or IL-6 receptor inhibitor. |
| Sustained Remission Dose Reduction | After GCs have been discontinued and a patient is in sustained remission, dose reduction of DMARDs (bDMARDs/tsDMARDs and/or csDMARDs) may be considered. | After GCs have been discontinued and a patient is in sustained remission, continuation of DMARDs (bDMARDs/ tsDMARDs and/or csDMARDs) is recommended, but dose reduction may be considered. |
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