Rheumatoid arthritis

Updated: EULAR recommendations for DMARDs in RA include JAK inhibitors

New EULAR recommendations on the use of DMARDs in the treatment of rheumatoid arthritis have included the use of JAK inhibitors for the first time.

Member of the 50 strong international Task Force Associate Professor Peter Nash said the therapy was not yet available in Europe but the group realised they will be an option for clinicians and their patients in the not too distant future.

“There’s half a dozen [JAK inhibitors] in the pipeline and EULAR didn’t want their guidelines to be out of date no sooner than they had been published,” he told the limbic.

Tofacitinib is approved in 45 countries around the world including Australia. Evidence for the use of baracitinib has been recently published in the New England Journal of Medicine and at EULAR 2016 and the American College of Rheumatology annual conference last year, Professor Nash noted.

However, he pointed out that in the new recommendations JAK inhibitors were elevated to ‘alternate first line’ for patients failing traditional therapies needing a biologic DMARD (see recommendation 9).

“The [recommendations] say TNF inhibitors are “preferred” based on opinion and only because we of 15 years of safety with TNF inhibitors follow-up in clinical trials and registries all over the world when compared to JAK inhibitors which are relatively new,” he said.

How do the EULAR guidelines differ from ACR?

Professor Josef Smolen from the Medical University of Vienna in Austria presented the new recommendations during a EULAR How To Treat (HOT) session. He told delegates they were closer to the most recent ACR recommendations than they had ever been before.

However, compared to the ACR 2015 guidelines the new EULAR recommendations were:

  1. Clearer about glucocorticoid use;
  2. Recommend using bDMARDs in combination with csDMARDs (MTX) rather than as monotherapy;
  3. do not distinguish RA patients by disease duration (early vs established) but by treatment phases (csDMARD-naïve, cs-DMARD experienced, and b-DMARD experienced; and
  4. Use prognostic factors for stratification.

 The 12 recommendations:

The new recommendations include 4 overarching principles and 12 recommendations. Using the Delphi voting process eight of the recommendations received the highest level of evidence. Following a meeting held in Vienna in April there was an anonymous ballot on the level of agreement.

On a scale of 0-10 most attained a mean of between 9 and 10 (see in brackets for level of agreement).

  1. Therapy with DMARDs should be started as soon as the diagnosis of RA is made (A;9.9)
  2. Treatment should be aimed at reaching a target of sustained remission or low disease activity in every patient (A; 9.5)
  3. Monitoring should be frequent in active disease (every 1-3 months); if there is no improvement by at most three months after start of treatment or the target has not been reached by 6 months, therapy should be adjusted (A; 9.8)
  4. MTZ should be part of the first treatment strategy (A;9.8)
  5. In patients with a contraindication to MTX (or early intolerance) leflunomide or sulfasalazine should be considered as part of the (first) treatment strategy (A;9.0)
  6. Short term glucocorticoids should be considered when initiating or changing csDMARDs, in different dose regimens and routes of administration, but should be tapered as rapidly as clinically feasible (A;8.7)
  7. If the treatment target is not achieved with the first csDMARD strategy in the absence of poor prognostic factors other csDMARDs should be considered (D; 8.5)
  8. If the treatment target is not achieved with the first csDMARD strategy, when poor prognostic factors are present, addition of a bDMARD or a bsDMARD should be considered; current practice would be to start a bDMARD (A;9.0)
  9. 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 to other bDMARDs (A;9.2)
  10. If a bDMARD or tsDMARD has failed, treatment with another bDMARD or a bsDMARD should be considered, if one TNF inhibitor therapy has failed, patients may receive another TNF inhibitor or an agent with another mode of action (A;9.3)
  11. If a patient in persistent remission after having tapered glucocorticoids, one can consider tapering bDMARDs, especially if this treatment is combined with a csDMARD (B; 9.0)
  12. If a patient is in persistent remission tapering the csDMARD could be considered (C; 8.5)

The full guidelines have recently been published in the Annals of the Rheumatic Diseases and can be accessed here.

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