Rheumatoid Arthritis Management (EULAR 2022)

Algorithm Steps

1. ▶

   Start

   Confirmed Rheumatoid Arthritis

   Diagnosis confirmed per ACR/EULAR 2010 criteria

   1. ●

      Action

      Overarching Principles

      Key principles for RA management

      • Treatment goal: remission or low disease activity
      • Base decisions on disease activity, structural damage, comorbidities
      • Shared decision-making with patient
      • Rheumatologist should primarily manage RA
      • Consider non-pharmacologic interventions (PT, OT)
      1. ◆

         Decision

         Poor Prognostic Factors?

         Assess for markers of severe/progressive disease

         • High disease activity (DAS28, SDAI, CDAI)
         • Positive RF and/or anti-CCP (especially high titers)
         • Early erosions on imaging
         • Elevated acute phase reactants (ESR, CRP)
         • Failure of ≥2 csDMARDs
         1. ●

            Action

            Phase 1: csDMARD Therapy

            Start conventional synthetic DMARD

            • Methotrexate FIRST-LINE (if no contraindications)
            • MTX dose: 15-25 mg/week (oral or SC)
            • Add folic acid 5-10 mg/week
            • If MTX contraindicated: leflunomide or sulfasalazine
            • Short-term glucocorticoid bridging allowed
            1. ⚠

               Warning

               ⚠️ Glucocorticoid Bridging

               Use with caution, taper within 3 months

               • Consider when initiating/changing csDMARD
               • Low-to-medium dose (≤7.5-10 mg pred equivalent)
               • Taper to discontinue within 3 months
               • Do NOT use as long-term monotherapy
               1. ◆

                  Decision

                  Target Achieved at 3-6 Months?

                  Assess disease activity (DAS28, SDAI, or CDAI)

                  • Remission: DAS28 <2.6, SDAI ≤3.3, CDAI ≤2.8
                  • Low disease activity: DAS28 ≤3.2, SDAI ≤11, CDAI ≤10
                  • If improvement ≥50% at 3mo, may continue to 6mo
                  • If no improvement at 3mo, escalate
                  1. ◆

                     Decision

                     Sustained Remission?

                     Remission maintained for ≥6-12 months

                     1. ●

                        Action

                        Consider Tapering

                        Cautious dose reduction in sustained remission

                        • First: taper glucocorticoids to zero
                        • Then: may taper b/tsDMARD (reduce dose or extend interval)
                        • Maintain csDMARD background therapy
                        • csDMARD tapering: only if very prolonged remission
                        • Monitor closely for flares
                        1. ✓

                           Outcome

                           RA Controlled

                           Remission or low disease activity achieved and maintained

                     2. ⚠

                        Warning

                        Refractory RA

                        Failed multiple mechanisms - consider clinical trial, specialist center

                  2. ●

                     Action

                     Phase 2: Add bDMARD or tsDMARD

                     After csDMARD failure (usually + MTX)

                     • bDMARDs: TNFi, IL-6i (tocilizumab, sarilumab), abatacept
                     • tsDMARDs: JAK inhibitors (tofacitinib, baricitinib, upadacitinib)
                     • Generally combine with MTX (or another csDMARD)
                     • TNFi biosimilars are preferred where available
                     1. ⚠

                        Warning

                        ⚠️ JAKi Safety Considerations

                        Per ORAL Surveillance and regulatory guidance

                        • Increased CV events vs TNFi in high-risk patients
                        • Increased VTE risk
                        • Increased risk of malignancy in some populations
                        • Age ≥65, current/past smokers, CV risk: prefer bDMARD first
                        • If using JAKi: lowest effective dose
                        1. ◆

                           Decision

                           Target Achieved at 3-6 Months?

                           Reassess disease activity on b/tsDMARD

                           1. ●

                              Action

                              Phase 3: Switch Mechanism

                              If first b/tsDMARD fails

                              • If TNFi fails: switch to different mechanism (IL-6i, abatacept, JAKi)
                              • If one mechanism fails: try different mechanism
                              • May try second TNFi if first failed for non-efficacy reason
                              • Rituximab: for seropositive RA after TNFi failure
                              1. ●

                                 Action

                                 Rituximab (CD20 Inhibitor)

                                 Especially for seropositive, refractory RA

                                 • 1000mg IV x2 doses (days 0, 14)
                                 • Repeat every 6-12 months based on activity
                                 • Seropositive (RF+/CCP+) patients respond better
                                 • Screen for hepatitis B/C before initiation