Rheumatoid Arthritis When Methotrexate Is Contraindicated or Not Tolerated
When methotrexate cannot be used due to a contraindication or early intolerance, and no poor prognostic factors are present, a specific first-line csDMARD strategy is indicated for rheumatoid arthritis.
Clinical Scenario
This protocol applies when all of the following conditions are met:
- Contraindication to methotrexate, or early intolerance has been established
- No high-level RF or ACPA positivity
- No persistently moderate or high disease activity despite prior csDMARD therapy
- No high swollen joint count or high acute phase reactant levels
- No early erosions and no failure of two or more csDMARDs
Treatment Approach
An alternative conventional synthetic DMARD forms the backbone of the first-line strategy, combined where appropriate with a short course of glucocorticoids as bridging support — with the full drug selection, dosing, and tapering schedule detailed in the protocol.
Clinical Goals
The target is at least 50% improvement in disease activity within 3 months, progressing to sustained remission or low disease activity by 6 months. If the target is not reached, therapy should be reassessed.
References
DOI: 10.1136/ard-2022-223356
- In patients with a contraindication to MTX (or early intolerance), leflunomide or sulfasalazine should be considered as part of the (first) treatment strategy.
- If the treatment target is not achieved with the first csDMARD strategy, in the absence of poor prognostic factors, other csDMARDs should be considered.
- Short-term glucocorticoids 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 should be aimed at reaching a target of sustained remission or low disease activity in every patient.
- 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.
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