New guidelines for treatment of rheumatoid arthritis

In 2017, the Czech Rheumatology Society issued the revised Guidelines for the Treatment of Rheumatoid Arthritis (RA). Theirmainstay is timely diagnosis of the disease and immediate initiation of effective treatment. Treatment strategy is guided by assessmentof disease activity using composite indexes at regular time intervals and by medication adjustment in the case of failureto achieve the treatment goal. Usually by the third month of treatment initiation, it is recommended to achieve at least a 50%reduction in the activity and, by the sixth month, the treatment goal, i.e. remission (alternatively low clinical activity). It is advisedto initiate monotherapy with methotrexate; when contraindicated or intolerated, the use of leflunomide or sulfasalazine shouldbe considered. In most cases, it is recommended to consider glucocorticoids at the onset of the disease (sometimes also in thecase of relapse of established RA); in addition to low doses, medium and/or high doses are acceptable. The duration of glucocorticoidadministration should ideally be less than three months, certainly not longer than six months. If there is failure of the initialtreatment strategy, the further steps are governed by the presence of adverse prognostic factors (high disease activity, positiveautoantibodies, and early erosive joint damage). If they are absent, a switch to another conventional synthetic disease-modifyingantirheumatic drug and/or their combination can be considered. In patients with adverse prognostic factors, it is appropriate toconsider the addition of biological therapy (TNF inhibitors, abatacept, tocilizumab or sarilumab, and, under certain circumstances,even rituximab) or the use of a targeted synthetic drug (Janus kinase inhibitors). Biosimilar drugs are thought to be equal toreference original biological drugs. In patients with sustained remission (with a duration of at least six months) who are no longertreated with glucocorticoids, it is possible to consider a dose reduction of the biological drug or prolongation of the administrationinterval. Complete withdrawal of the biological drug often results in a flare-up of the disease. The Guidelines provide practical guidance on how to proceed with treatment of patients with RA in the majority of cases.

Keywords: rheumatoid arthritis, disease-modifying antirheumatic treatment, biological therapy, guidelines, remission