Treatment of early stage rheumatoid arthritis should continue to include conventional synthetic disease modifying drugs (DMARDs) plus steroids, advises the European League against Rheumatism (EULAR) in its latest recommendations on managing the disease, published in the Annals of the Rheumatic Diseases.

But the steroid dose should not exceed 10 mg a day, and should only be prescribed for a maximum of six months, says EULAR.

Only if this strategy fails to significantly ease or reverse symptoms, should a biological DMARD be deployed, it says. And only then, if the disease is likely to progress or is severe. Otherwise, another conventional synthetic DMARD should be used, along with steroids.

The latest recommendations on the safety and effectiveness of DMARDs to treat rheumatoid arthritis update those published in 2010 in the wake of the availability of new drugs and further experience with treatment strategies.

They publish just ahead of the start of the international annual American College of Rheumatology (ACR) congress, which runs from October 25-30 in San Diego.

DMARDs, which are the mainstay of treatment for the disease, work by blocking the inflammatory processes characteristic of rheumatoid arthritis and curbing the amount of associated joint damage. They are either synthetic or biological.

The 2013 recommendations were developed by an international taskforce, which included four patient representatives, 24 rheumatologists, an infectious disease specialist, a health economist and three research fellows from 11 European countries and the US.

The taskforce drew on published evidence from three systematic reviews on the use of synthetic and biological DMARDs for rheumatoid arthritis, and expert opinion, to reach a consensus on 14 treatment recommendations and three guiding principles.

The recommendations emphasise that not only should treatment be based on shared decision making between rheumatologist and patient, but that rheumatologists should primarily manage patients with this condition.

And treatment should take into consideration the high personal, societal, and medical costs of rheumatoid arthritis.

Other key clinical recommendations include:

  • Treatment should aim for remission (as recently newly defined by the ACR and EULAR) or low disease activity at the very least.
  • Active disease should be regularly reviewed every 1-3 months and treatment adjusted accordingly.
  • Among the biologics, a class of drugs known as tumour necrosis factor inhibitors; abatacept; tocilizumab; and in certain situations, rituximab, are essentially comparable when it comes to effectiveness.
  • If the first treatment strategy using a biological DMARD fails, any other biological DMARD can be substituted.
  • Although not currently available everywhere yet, Tofacitinib, a targeted synthetic DMARD, could be used, where licensed, after at least one biological DMARD has not worked.
  • Treatment and intended outcome may have to be adjusted to take account of other underlying conditions.

The rapidly evolving treatment of rheumatoid arthritis is likely to prompt the need for further updates in two to three years' time, say the taskforce authors.

"Until then, we hope that the current recommendations find their way into clinical practice either directly or through national societies that may wish to use them as a framework for development of local guidance documents," they suggest.