Updated guidelines on treating rheumatoid arthritis from the American College of Rheumatology focus on the importance of maximising treatment with methotrexate and avoiding use of glucocorticoids where possible.

And while there had been “vigorous debate” over whether the next step should be triple therapy with the addition of sulfasalazine and hydroxychloroquine, the addition of a biologic or targeted synthetic DMARD was ultimately chosen because it prioritised “maximising improvement as quickly as possible”, the recommendations explain.

However, the updated recommendations from the 2015 guidance remains conditional because triple therapy may be preferred in lower resource settings as well as in patients with comorbidities for where there may be significantly less risk of adverse events, the panel said.

Decisions should also incorporate patient preference, the recommendations said, with no current recommendation for a choice of a specific biologic or targeted synthetic DMARD when adjusting treatment.

While methotrexate monotherapy remains the mainstay of treatment initially, except in patients with low disease activity where hydroxychloroquine is preferred followed by sulfasalazine, initiation of a conventional DMARD should be done without short-term glucocorticoids, the panel decided.

This recommendation differs from the 2019 EULAR guidance which recommended short-term glucocorticoids be considered when initiating or changing conventional DMARDs although tapered as rapidly as possible.

The ACR voting panel agreed that glucocorticoids should not be systematically prescribed but made the recommendation conditional because of an acknowledgment that short-term glucocorticoids are often necessary to alleviate symptoms prior to the onset of action of DMARDs.

Doses of methotrexate should be maximised before switching or adding other DMARDs including switching to subcutaneous methotrexate first for patients taking oral methotrexate who are not at target, the panel decided.

Once a biologic or targeted synthetic DMARD has been used and patients are not at target, a DMARD of a different class is conditionally recommended over switching to an another option within the same class, the ACR recommended while noting that patient and clinician preferences are likely to vary based on prior experiences with specific DMARDs.

Patients should be at target (low disease activity or remission) on DMARDs for at least six months before tapering is considered, the guidelines add.

The panel also recommended that continuation of all DMARDs at their current dose is conditionally preferred over a dose reduction of a DMARD and dose reduction is conditionally recommended over gradual discontinuation of a DMARD.