EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update

JS Smolen, RBM Landewe, SA Bergstra, A Kerschbaumer, A Sepriano, D Aletaha, R Caporali, CJ Edwards, Kimme Hyrich, JE Pope, S de Souza, TA Stamm, T Takeuchi, P Verschueren, KL Winthrop, A Balsa, JM Bathon, Maya Buch, GR Burmester, F ButtgereitMH Cardiel, K Chatzidionysiou, C Codreanu, M Cutolo, AA den Broeder, K El Aoufy, A Finckh, JE Fonseca, JE Gottenberg, EA Haavardsholm, A Iagnocco, Kim Lauper, ZG Li, IB McInnes, EF Mysler, P Nash, G Poor, GG Ristic, F Rivellese, A Rubbert-Roth, H Schulze-Koops, N Stoilov, A Strangfeld, A van der Helm-van Mil, E van Duuren, TPMV Vlieland, R Westhovens, D van der Heijde

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Objectives To provide an update of the European League Against Rheumatism (EULAR) rheumatoid arthritis (RA) management recommendations addressing the most recent developments in the field.
Methods An international Task Force was formed and solicited three systemic literature research activities on safety and efficacy of disease modifying antirheumatic drugs (DMARDs) and glucocorticoids. The new evidence was discussed in light of the last update from 2019. A predefined voting process was applied to each overarching principle and recommendation. Levels of evidence and strengths of recommendation were assigned to -and participants finally voted on- the level of agreement with each item.
Results The task force agreed on 5 overarching principles and 11 recommendations concerning use of conventional synthetic (cs) DMARDs (methotrexate [MTX], leflunomide, sulfasalazine); glucocorticoids (GCs); biological (b) DMARDs (tumour necrosis factor inhibitors [adalimumab, certolizumab pegol, etanercept, golimumab, infliximab including biosimilars], abatacept, rituximab, tocilizumab, sarilumab and targeted synthetic [ts] DMARDs, namely the Janus kinase [JAK] inhibitors tofacitinib, baricitinib, filgotinib, upadacitin). Guidance on monotherapy, combination therapy, treatment strategies (treat-to-target) and tapering on sustained clinical remission is provided. Safety aspects, including risk of major cardiovascular events (MACEs) and malignancies, costs and sequencing of b/tsDMARDs were all considered. Initially, MTX plus GCs is recommended and upon insufficient response to this therapy within 3 to 6 months, treatment should be based on stratification according to risk factors; With poor prognostic factors (presence of autoantibodies, high disease activity, early erosions or failure of two csDMARDs), any bDMARD should be added to the csDMARD; after careful consideration of risks of MACEs, malignancies and/or thrombo-embolic events tsDMARDs may also be considered in this phase. If the first bDMARD (or tsDMARD) fails, any other bDMARD (from another or the same class) or tsDMARD (considering risks) is recommended. With sustained remission, DMARDs may be tapered but not be stopped. Levels of evidence and levels of agreement were high for most recommendations.
Conclusions These updated EULAR recommendations provide consensus on RA management including safety, effectiveness, and cost.
Original languageEnglish
Pages (from-to)3-18
Number of pages16
JournalAnnals of Rheumatic Diseases
Issue number1
Early online date10 Nov 2022
Publication statusPublished - 3 Jan 2023


  • Antirheumatic Agents
  • Arthritis
  • Biological Therapy
  • Rheumatoid


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