title: EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2013 update.
abstract: In this article, the 2010 European League against Rheumatism (EULAR) recommendations for the management of rheumatoid arthritis (RA) with synthetic and biological disease-modifying antirheumatic drugs (sDMARDs and bDMARDs, respectively) have been updated. The 2013 update has been developed by an international task force, which based its decisions mostly on evidence from three systematic literature reviews (one each on sDMARDs, including glucocorticoids, bDMARDs and safety aspects of DMARD therapy); treatment strategies were also covered by the searches. The evidence presented was discussed and summarised by the experts in the course of a consensus finding and voting process. Levels of evidence and grades of recommendations were derived and levels of agreement (strengths of recommendations) were determined. Fourteen recommendations were developed (instead of 15 in 2010). Some of the 2010 recommendations were deleted, and others were amended or split. The recommendations cover general aspects, such as attainment of remission or low disease activity using a treat-to-target approach, and the need for shared decision-making between rheumatologists and patients. The more specific items relate to starting DMARD therapy using a conventional sDMARD (csDMARD) strategy in combination with glucocorticoids, followed by the addition of a bDMARD or another csDMARD strategy (after stratification by presence or absence of adverse risk factors) if the treatment target is not reached within 6 months (or improvement not seen at 3 months). Tumour necrosis factor inhibitors (adalimumab, certolizumab pegol, etanercept, golimumab, infliximab, biosimilars), abatacept, tocilizumab and, under certain circumstances, rituximab are essentially considered to have similar efficacy and safety. If the first bDMARD strategy fails, any other bDMARD may be used. The recommendations also address tofacitinib as a targeted sDMARD (tsDMARD), which is recommended, where licensed, after use of at least one bDMARD. Biosimilars are also addressed. These recommendations are intended to inform rheumatologists, patients, national rheumatology societies and other stakeholders about EULAR's most recent consensus on the management of RA with sDMARDs, glucocorticoids and bDMARDs. They are based on evidence and expert opinion and intended to improve outcome in patients with RA.
authors.affiliation: Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, , Vienna, Austria.
authors.forename: Josef S
authors.initials: JS
authors.lastname: Smolen
authors.forename: Robert
authors.initials: R
authors.lastname: Landewé
authors.forename: Ferdinand C
authors.initials: FC
authors.lastname: Breedveld
authors.forename: Maya
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authors.lastname: Buch
authors.forename: Gerd
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authors.lastname: Burmester
authors.forename: Maxime
authors.initials: M
authors.lastname: Dougados
authors.forename: Paul
authors.initials: P
authors.lastname: Emery
authors.forename: Cécile
authors.initials: C
authors.lastname: Gaujoux-Viala
authors.forename: Laure
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authors.lastname: Gossec
authors.forename: Jackie
authors.initials: J
authors.lastname: Nam
authors.forename: Sofia
authors.initials: S
authors.lastname: Ramiro
authors.forename: Kevin
authors.initials: K
authors.lastname: Winthrop
authors.forename: Maarten
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authors.lastname: de Wit
authors.forename: Daniel
authors.initials: D
authors.lastname: Aletaha
authors.forename: Neil
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authors.lastname: Betteridge
authors.forename: Johannes W J
authors.initials: JW
authors.lastname: Bijlsma
authors.forename: Maarten
authors.initials: M
authors.lastname: Boers
authors.forename: Frank
authors.initials: F
authors.lastname: Buttgereit
authors.forename: Bernard
authors.initials: B
authors.lastname: Combe
authors.forename: Maurizio
authors.initials: M
authors.lastname: Cutolo
authors.forename: Nemanja
authors.initials: N
authors.lastname: Damjanov
authors.forename: Johanna M W
authors.initials: JM
authors.lastname: Hazes
authors.forename: Marios
authors.initials: M
authors.lastname: Kouloumas
authors.forename: Tore K
authors.initials: TK
authors.lastname: Kvien
authors.forename: Xavier
authors.initials: X
authors.lastname: Mariette
authors.forename: Karel
authors.initials: K
authors.lastname: Pavelka
authors.forename: Piet L C M
authors.initials: PL
authors.lastname: van Riel
authors.forename: Andrea
authors.initials: A
authors.lastname: Rubbert-Roth
authors.forename: Marieke
authors.initials: M
authors.lastname: Scholte-Voshaar
authors.forename: David L
authors.initials: DL
authors.lastname: Scott
authors.forename: Tuulikki
authors.initials: T
authors.lastname: Sokka-Isler
authors.forename: John B
authors.initials: JB
authors.lastname: Wong
authors.forename: Désirée
authors.initials: D
authors.lastname: van der Heijde
mesh_terms: D000465:Algorithms; D018501:Antirheumatic Agents / Q000627:therapeutic use*; D001172:Arthritis, Rheumatoid / Q000188:drug therapy*; D001688:Biological Products / Q000627:therapeutic use*; D004359:Drug Therapy, Combination; D019317:Evidence-Based Medicine / Q000379:methods; D005938:Glucocorticoids / Q000627:therapeutic use; D006801:Humans; D007166:Immunosuppressive Agents / Q000627:therapeutic use; D014409:Tumor Necrosis Factor-alpha / Q000037:antagonists & inhibitors
chemical_list: D018501:Antirheumatic Agents; D001688:Biological Products; D005938:Glucocorticoids; D007166:Immunosuppressive Agents; D014409:Tumor Necrosis Factor-alpha
keywords: DMARDs (biologic); DMARDs (synthetic); Early Rheumatoid Arthritis; Rheumatoid Arthritis; Treatment