2017 recommendations of the Czech Society for Rheumatology for the pharmacological treatment of rheumatoid arthritis.
Authors:
L. Šenolt; H. Mann; J. Závada; K. Pavelka; J. Vencovský
Authors place of work:
Revmatologický ústav, Revmatologická klinika 1. LF UK, Praha
Published in the journal:
Čes. Revmatol., 25, 2017, No. 1, p. 8-24.
Category:
Recommendation
Summary
Based on the current knowledge about the treatment of rheumatoid arthritis (RA), the working group of the Czech Society for Rheumatology presents the updated recommendations for the pharmacotherapy of RA. The basic prerequisite for successful treatment is early diagnosis of the disease and prompt initiation of effective therapy. Pharmacotherapy of RA should be based on the treat to target strategy, the substance of which is the assessment of disease activity using composite indices at regular time intervals and adjustment of the therapy according to whether the predetermined target for treatment has been reached. Treat to target approach applies generally, irrespective of the medication. The goal of treatment for RA is a state of remission or at least low clinical disease activity, which should be achieved quickly, usually within six months of commencement of the treatment, and this condition should be permanently maintained. The treatment should be initiated with a monotherapy using a conventional synthetic disease-modifying anti-rheumatic drug (csDMARD), in most cases, methotrexate. In case of contraindication of or intolerance to methotrexate administration of leflunomide or sulfasalazine can be considered. In patients with high activity at the onset of the disease or with relapse during established RA glucocorticoids can be used with a gradual reduction of the dose until withdrawal (ideally for a period shorter than three months). If high disease activity persists after 3 months of intensive treatment, or if the treatment target is not achieved after 6 months, the treatment should be adjusted accordingly. The treatment approach after the failure of the first csDMARD is driven by the presence of unfavorable prognostic factors (high disease activity, positivity of autoantibodies, and early erosive joint damage). If there are no risk factors for severe disease course present, changing to a different csDMARD, possibly a combination of more csDMARD, can be considered. In patients with unfavorable prognostic factors after failure of csDMARD administration of biologic therapy is recommended. There are no substantial differences in efficiency among the various biological agents. Thus, as the first-line drug TNFα inhibitors (adalimumab, certolizumab pegol, etanercept, golimumab, infliximab, including biosimilar products) are usually employed. However, abatacept, rituximab or tocilizumab can be used as well. Once targeted synthetic agents (tsDMARD, e.g. Janus kinase inhibitors) are available in the Czech Republic, it will be possible to consider these products as well. If a loss of response to first-line biological therapy occurs, it is appropriate to switch to another biological agent or tsDMARD. After treatment failure of a TNFα inhibitor, a different TNFα inhibitor or a drug with a different mechanism of action can be used. In patients in sustained remission lasting at least six months, who are not receiving glucocorticoids anymore, it is possible to consider reducing the dose of the biological agent or extending its administration interval. Discontinuation of biological therapy often leads to a flare, especially in patients with longstanding RA. The presented recommendations of the Czech Society for Rheumatology are not a binding regulation, rather a practical guide on how to proceed with treatment of patients with RA. In their application another aspects must also be taken into account, such as the general health condition, other diseases, concomitant therapy, and contraindications that can modify the treatment approach.
Keywords:
Rheumatoid arthritis, recommendations, disease- modifying anti-rheumatic drugs, remission
Zdroje
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Štítky
Dermatology & STDs Paediatric rheumatology RheumatologyČlánok vyšiel v časopise
Czech Rheumatology
2017 Číslo 1
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