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EULAR updates guidelines on rheumatoid arthritis

By News team

First-line therapy for rheumatoid arthritis should be with methotrexate, given either on its own or in combination with other conventional disease-modifying antirheumatic drugs (DMARDs), say updated guidelines on use of DMARDs from the European League Against Rheumatism (EULAR) (Annals of Rheumatic Disease, online 25 October 2013).

Previous guidelines favoured DMARD monotherapy for initial therapy but EULAR says that several studies have now suggested that combination treatment may be superior to methotrexate alone. So both options are included, with choice depending on patient preference and expectation of adverse effects.

Low-dose glucocorticoids should also be part of the initial treatment strategy for up to six months, but should be tapered as rapidly as feasible.

If the treatment target is not reached in six months (or improvement not seen at three months), the recommendation is either a different conventional DMARD strategy or addition of a biological DMARD, depending on prognostic factors. On choice of biological agent, the guideline no longer states a preference for a tumour necrosis factor (TNF) inhibitor. It says that TNF inhibitors, abatacept, tocilizumab and, under certain circumstances, rituximab, have similar efficacy and safety.

Would be useful for NICE to take on board some of the recommendations

Ian Scott, rheumatology pharmacist at Peterborough City Hospital, said that EULAR is highly respected in the UK and that the guidelines include some recommendations that it would be useful for the National Institute for Health and Care Excellence to take on board. However, he said that the suggestion that a biological agent could be used after one conventional DMARD is unlikely to be adopted in the UK, where two or more conventional DMARDs are still tried first.

The guidelines refer to possible reduction of biological DMARD dose (or even drug withdrawal) in patients in persistent remission. Mr Scott commented that the key trial which showed this as a possibility, OPTIMA, used a biological agent soon after diagnosis. Trials that introduced a biological agent at a later stage (more in keeping with UK practice) did not produce such promising results. "It would not be financially feasible for all patients to start a biologic on diagnosis. Therefore further work is required to identify which patients would benefit from such an approach," he said.

EULAR recommends frequent monitoring (every one to three months) after starting treatment. "There are capacity problems for rheumatologists . . . , but this is a niche where specialist pharmacists have found a role," Mr Scott said.

Citation: The Pharmaceutical Journal DOI: 10.1211/PJ.2013.11129599

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