New guidelines will lead to questions about treating rheumatoid arthritis, especially with the plethora of medication options. For more information, see topic on Overview of rheumatoid arthritis.
Which medication is first-line? Recommend sticking with oral methotrexate 7.5 mg once weekly for most patients. Generally advise titrating to at least 15 mg/week within 4 to 6 weeks and up to 25 mg/week if needed. But be aware that hydroxychloroquine or sulfasalazine can be enough for patients with low disease activity and tend to be better tolerated.
What are tips to optimize methotrexate? Educate all patients on methotrexate to take folic acid (usually 1 mg/day) to limit GI upset, liver damage, mouth sores, etc.
Explain that it's okay to take folic acid and methotrexate on the same day, there's no proof this reduces methotrexate efficacy. Consider additional strategies if GI upset is an issue or there's an inadequate response to higher doses of oral methotrexate. For example, suggest splitting once-weekly oral methotrexate into 3 doses given 12 hours apart or changing to once-weekly subcutaneous methotrexate, before adding or switching to other medications.
What are considerations with oral steroids? Suggest limiting them to the lowest dose and shortest duration possible. And don't automatically recommend adding steroids when starting treatment. Risks often outweigh benefits and patients may not want to taper off due to fear of having a disease flare.What if methotrexate isn't enough? Weigh pros and cons of adding another med after at least 3 months of optimized methotrexate. For instance, point out that biologics (Humira, etc) are injectable, but many have a longer track record than oral Janus kinase inhibitors (Xeljanz, etc), whose risks are piling up (thrombosis, etc).
REFERENCES
Fraenkel L, Bathon JM, England BR, St Clair EW, Arayssi T, Carandang K, Deane KD, Genovese M, Huston KK, Kerr G, Kremer J, Nakamura MC, Russell LA, Singh JA, Smith BJ, Sparks JA, Venkatachalam S, Weinblatt ME, Al-Gibbawi M, Baker JF, Barbour KE, Barton JL, Cappelli L, Chamseddine F, George M, Johnson SR, Kahale L, Karam BS, Khamis AM, Navarro-Millán I, Mirza R, Schwab P, Singh N, Turgunbaev M, Turner AS, Yaacoub S, Akl EA. 2021 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis. Arthritis Care Res (Hoboken). 2021 Jul;73(7):924-939. Available at: https://pubmed.ncbi.nlm.nih.gov/34101387
Smolen JS, Landewé RBM, Bijlsma JWJ, Burmester GR, Dougados M, Kerschbaumer A, McInnes IB, Sepriano A, van Vollenhoven RF, de Wit M, Aletaha D, Aringer M, Askling J, Balsa A, Boers M, den Broeder AA, Buch MH, Buttgereit F, Caporali R, Cardiel MH, De Cock D, Codreanu C, Cutolo M, Edwards CJ, van Eijk-Hustings Y, Emery P, Finckh A, Gossec L, Gottenberg JE, Hetland ML, Huizinga TWJ, Koloumas M, Li Z, Mariette X, Müller-Ladner U, Mysler EF, da Silva JAP, Poór G, Pope JE, Rubbert-Roth A, Ruyssen-Witrand A, Saag KG, Strangfeld A, Takeuchi T, Voshaar M, Westhovens R, van der Heijde D. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2019 update. Ann Rheum Dis. 2020 Jun;79(6):685-699. Available at: https://pubmed.ncbi.nlm.nih.gov/31969328