Rheumatoid Arthritis When Prior bDMARD or tsDMARD Has Not Achieved Treatment Targets
This protocol applies to patients with rheumatoid arthritis who have no contraindication to methotrexate and no poor prognostic factors, and whose previous biologic or targeted synthetic DMARD regimen did not meet the defined disease-activity targets.
Patient Scenario
No contraindication or early intolerance to methotrexate. Absence of poor prognostic factors: no high-level RF or ACPA positivity, no persistently moderate or high disease activity on csDMARD therapy, no high swollen joint count, no elevated acute phase reactants, no early erosions, and no prior failure of two or more csDMARDs.
Previous Treatment — Failure Condition
The preceding step involved adding a bDMARD or a JAK inhibitor (tsDMARD) to the existing csDMARD regimen. This protocol is indicated when that approach did not achieve at least 50% improvement in disease activity within 3 months, or did not reach sustained remission or low disease activity by 6 months.
Next-Line Approach — Partial Overview
When a bDMARD or tsDMARD has not reached treatment targets, the structured approach involves switching to a different agent within the bDMARD or tsDMARD class, with the specific selection guided in part by which therapeutic mechanism has already been used. The complete agent options, sequencing logic, and decision algorithm are available in the full protocol.
Treatment goal: ≥50% improvement in disease activity by 3 months; sustained remission or low disease activity by 6 months.
References
DOI: 10.1136/ard-2022-223356
- MTX should be 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 a bDMARD or tsDMARD has failed, treatment with another bDMARD or a tsDMARD should be considered; if one TNF or IL-6 receptor inhibitor therapy has failed, patients may receive an agent with another mode of action or a second TNF- or IL-6 receptor inhibitor.
- 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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