Rheumatoid Arthritis with Poor Prognostic Factors: Treatment When Initial Biologic or Targeted Therapy Did Not Reach Targets

This protocol addresses patients with rheumatoid arthritis who have no contraindication (or only early intolerance) to methotrexate, carry one or more poor prognostic factors, and whose initial advanced therapy did not reach the expected disease activity targets.

Clinical situation

Poor prognostic factors are present: RF and/or ACPA positivity (especially at high levels), persistently moderate or high disease activity despite conventional DMARD therapy, high swollen joint count, elevated acute phase reactants, early erosive joint disease, or prior failure of two or more conventional synthetic DMARDs.

Previous treatment — why this protocol applies

The preceding step added a biologic DMARD or a JAK inhibitor to the existing conventional synthetic DMARD. This strategy 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 — meeting the criteria to advance to the current protocol.

Treatment approach

The next step involves switching to a different biologic or targeted synthetic DMARD — in some cases to one with a different mechanism of action than the agent that failed. The specific agent selection, sequencing, and supporting therapy are set out in the full structured protocol.

Treatment targets

The goal is at least 50% improvement in disease activity within 3 months of the new regimen, and sustained remission — defined by ACR-EULAR Boolean criteria (swollen joint count, tender joint count, CRP, and patient global assessment) — or low disease activity by 6 months.

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References

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.
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.
Presence of RF and/or ACPA, especially at high levels.
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.

DOI: 10.1136/ard-2022-223356

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