Treatment of Rheumatoid Arthritis Without Poor Prognostic Factors and No Contraindication to Methotrexate
This first-line protocol applies to patients with rheumatoid arthritis who can tolerate methotrexate and who do not carry features associated with a worse prognosis.
Applicable Clinical Scenario
- No contraindication to methotrexate and no early intolerance
- No RF or ACPA positivity at high levels
- No persistently moderate or high disease activity despite prior csDMARD therapy
- No high swollen joint count and no high acute phase reactant levels
- No early erosions on imaging
- No failure of two or more csDMARDs
Treatment Approach
The strategy is anchored by methotrexate with folic acid supplementation as the core conventional synthetic DMARD, combined with a short course of glucocorticoids used as bridging therapy — with a clear plan to taper and stop glucocorticoids early in the treatment course.
Full sequencing, dosing guidance, and route of administration details are in the structured protocol →
Clinical Targets
The goal is at least 50% improvement in disease activity within 3 months, progressing to sustained remission — defined by strict joint, CRP, and patient-reported criteria — or low disease activity by 6 months. If the target is not reached at 3 months, therapy should be reassessed.
REFERENCES
DOI: 10.1136/ard-2022-223356
- 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.
- 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.
- rheumatologists are urged to either apply a single parenteral dose of GCs, such as parenteral (intramuscular) methylprednisolone, as a bridging therapy or predefine a tapering and discontinuation scheme when starting oral GC, with stopping GC to be planned upfront within 3 months; by that time, the csDMARD, such as MTX, should have already shown its efficacy.
- Treatment should be aimed at reaching a target of sustained remission or low disease activity in every patient.
- the general treat-to-target approach, as recommended in the EULAR guidance, focuses on at least a 50% improvement in disease activity within 3 months and the attainment of the main treatment target, which is remission in early and low disease activity in long-standing disease, at about 6 months.
- ACR and EULAR have endorsed an increase of the PGA threshold in the Boolean definition of remission from 1 to 2 cm on a 10 cm VAS, while continuing to keep swollen and tender joints at a maximum of 1 and C reactive protein (CRP) at a maximum of 1 mg/dL.
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