Recommendations of the Czech Society of Rheumatology for the pharmacological treatment of rheumatoid arthritis – update in 2024
Authors:
kol. Črs L. Za Šenolt; H. Mann; M. Tomčík; T. Zitko; J. Závada; D. Tegzová; M. Olejárová; S. Macháček; P. Doležalová; E. Dokoupilová; H. Šmucrová; L. Bortlík; K. Bubová; P. Horák; K. Pavelka; J. Vencovský
Authors‘ workplace:
Revmatologický ústav Praha Revmatologická klinika 1. LF UK, Praha
Published in:
Čes. Revmatol., 32, 2024, No. 1, p. 7-24.
Category:
Recomendation
Overview
A working group of the Czech Society of Rheumatology (CRS) is presenting updated recommendations for the pharmacotherapy of rheumatoid arthritis (RA) based on the latest knowledge on the treatment of RA. Early diagnosis of the disease and immediate initiation of effective therapy based on a treatment-to-target strategy, which involves assessing disease activity using composite indices at regular time intervals and adjusting therapy according to whether a predetermined treatment goal has been achieved, remain essential for successful treatment. The treat-to-target strategy applies generally, regardless of the drug used. The treatment goal is remission in the early phase of the disease, or at least low clinical activity in the case of long-standing disease, and these states should generally be achieved within 6 months of initiation of therapy and should be sustained. Initial treatment with methotrexate (MTX) together with glucocorticoids is recommended. Strong emphasis is placed on short-term glucocorticoid administration, and dose reduction to complete discontinuation by month 3 at the latest. If MTX is contraindicated or not tolerated, leflunomide or sulfasalazine may be considered. If high disease activity persists after 3 months of intensive treatment or the treatment goal is not achieved after 6 months, then treatment should be adjusted in the context of the presence of negative prognostic factors (high disease activity, positive autoantibodies, and early erosive joint damage). If risk factors for a severe disease course are not present, a switch to another conventional synthetic disease-modifying antirheumatic drug (DMARD), or possibly a combination of two of them, may be considered. If negative prognostic factors are present, biologic therapy - TNF inhibitors (adalimumab, certolizumab pegol, etanercept, golimumab, infliximab), abatacept, tocilizumab, sarilumab or rituximab; including biosimilars - should be added to conventional synthetic DMARDs. After careful consideration of the risk of serious cardiovascular and cancer events, drugs from the Janus kinase (JAK) inhibitor class may be considered at this stage of treatment. These recommendations introduce for the first time the possibility of deploying TNF-blocking therapy in early RA alongside MTX in the setting of increased risk of severe disease. If first-line biologic therapy or JAK inhibitors fail, then a drug with a different mechanism of action is appropriate, but after failure of treatment with TNF, IL-6R, or JAK inhibitors, a drug from the same group may be considered. The current update of the guideline addresses the management of difficult-to-treat RA after failure of multiple biologics or JAK inhibitors and the treatment of patients with the presence of significant comorbidities. The CRS position on treatment with JAK inhibitors is also presented. In patients in persistent remission lasting at least 6 months who are no longer treated with glucocorticoids, dose reduction or extension of the DMARD dosing interval may be considered, but complete withdrawal of a conventional synthetic or biologic drug or JAK inhibitor is not recommended because it often leads to disease flare. The present update of the CRS recommendations is not a binding prescription, but a practical guide on how to treat patients with RA in routine clinical practice with regard to safety, efficacy, and costs.
Keywords:
recommendations – multimorbidity – Janus kinase inhibitors – rheumatoid arthritis – disease-modifying antirheumatic therapy – bio-logical therapy – difficult-to-treat disease – remis-sion
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