EULAR recommendations for the management of rheumatoid arthritis with synthetic and biologic disease modifying antirheumatic drugs: 2025 update.

Objectives To provide an update of the European Alliance of Associations for Rheumatology (EULAR) rheumatoid arthritis (RA) management recommendations addressing the most recent insights.

Methods An international Task Force was formed with a wide expertise and solicited two systemic literature research activities on safety and efficacy of disease modifying antirheumatic drugs (DMARDs). New evidence was discussed considering the update from 2022. A voting process was applied to each item. Levels of evidence and strengths of recommendation were assigned and participants voted on the levels of agreement.

Results The task force agreed on 5 overarching principles and reduced the number of recommendations to 9 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 inhibitors [JAKi] tofacitinib, baricitinib, filgotinib, upadacitinib). Guidance on monotherapy, combination therapy, treatment strategies (treat-to-target) and tapering following clinical remission is provided. Safety aspects, including risk of major cardiovascular events (MACEs) and malignancies, costs and sequencing of b/tsDMARDs were considered. Initially, MTX ideally in combination with short-term GCs is recommended; upon insufficient response 3 to 6 months, treatment should no longer be based on stratification according to risk factors; failure of the first MTX strategy is considered enough to add a b-DMARD; after careful consideration of risks including MACEs, malignancies and/or thrombo-embolic events JAKi may also be considered. 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 caution is required as stopping often leads to a flare. Levels of evidence and levels of agreement were high for most recommendations.

Conclusions These updated EULAR recommendations provide consensus on RA management based on currently available evidence regarding efficacy, safety and cost.