Rheumatoid Arthritis: What to Do When the csDMARD Strategy Did Not Reach Targets (No Poor Prognostic Factors)
This protocol addresses patients with rheumatoid arthritis who tolerate methotrexate, have no poor prognostic features, and whose previous conventional synthetic DMARD strategy failed to achieve the required clinical targets.
Clinical scenario
- No contraindication or early intolerance to methotrexate
- No RF or ACPA positivity at high levels
- No persistently moderate or high disease activity despite csDMARD therapy
- No high swollen joint count or elevated acute phase reactants
- No early erosions
- No failure of two or more csDMARDs
Previous step did not meet targets
The prior treatment — adding or switching to a second conventional synthetic DMARD (leflunomide or sulfasalazine) combined with short-term glucocorticoids — did not achieve at least 50% improvement in disease activity within 3 months, or sustained remission / low disease activity by 6 months. This protocol is the next step taken after that failure.
Treatment goals
- At least 50% improvement in disease activity within 3 months
- Sustained remission or low disease activity by 6 months
Treatment approach (overview only)
The approach at this stage involves adding a biological DMARD (bDMARD) in combination with the ongoing csDMARD. A JAK inhibitor may also be considered, subject to individual assessment of relevant risk factors. The complete agent selection, sequencing, and clinical decision criteria are in the full protocol.
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.
- If the treatment target is not achieved with the first csDMARD strategy, when poor prognostic factors are present, a bDMARD should be added; JAK-inhibitors may be considered, but pertinent risk factors must be taken into account.
- 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 with other bDMARDs.
- 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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