________________________________ Chronic Pain Syndromes: Current Concepts and Treatment Strategies
2021 ACR GUIDELINE RECOMMENDATIONS FOR THE TREATMENT OF RHEUMATOID ARTHRITIS Patient Population Recommendation(s) DMARD-naïve patients with moderate-to-high disease activity Methotrexate monotherapy is strongly recommended over hydroxychloroquine or sulfasalazine; bDMARD or tsDMARD monotherapy; orcombination of methotrexate plus a non-TNF inhibitor bDMARD or tsDMARD.
Methotrexate is conditionally recommended over leflunomide, dual or triple csDMARD therapy, and combination of methotrexate plus a TNF inhibitor. Initiation of a csDMARD without short-term (less than three months) glucocorticoids is conditionally recommended over initiation of a csDMARD with short-term glucocorticoids. Initiation of a csDMARD without longer-term (three months or more) glucocorticoids is strongly recommended over initiation of a csDMARD with longer- term glucocorticoids. Hydroxychloroquine is conditionally recommended over other csDMARDs. Sulfasalazine is conditionally recommended over methotrexate. Methotrexate is conditionally recommended over leflunomide. Methotrexate monotherapy is conditionally recommended over the combination of methotrexate plus a bDMARD or tsDMARD
DMARD-naïve patients with low disease activity
csDMARD-treated, methotrexate- naïve patients with moderate-to-high disease activity a
All patients receiving methotrexate Oral methotrexate is conditionally recommended over subcutaneous methotrexate for patients initiating methotrexate.
Initiation/titration of methotrexate to a weekly dose of at least 15 mg within 4 to 6 weeks is conditionally recommended over initiation/titration to a weekly dose of <15 mg. A split dose of oral methotrexate over 24 hours or weekly subcutaneous injections, and/or an increased dose of folic/folinic acid, is conditionally recommended over switching to alternative DMARD(s) for patients not tolerating oral weekly methotrexate. Switching to subcutaneous methotrexate is conditionally recommended over the addition of/switching to alternative DMARD(s) for patients taking oral methotrexate who are not at target. A TTT approach is strongly recommended over usual care for patients who have not been previously treated with bDMARDs or tsDMARDs. A TTT approach is conditionally recommended over usual care for patients who have had an inadequate response to bDMARDs or tsDMARDs. A minimal initial treatment goal of low disease activity is conditionally recommended over a goal of remission. Addition of a bDMARD or tsDMARD is conditionally recommended over triple therapy for patients taking maximally tolerated doses of methotrexate who are not at target. Switching to a bDMARD or tsDMARD of a different class is conditionally recommended over switching to a bDMARD or tsDMARD belonging to the same class for patients taking a bDMARD or tsDMARD who are not at target. Addition of/switching to DMARDs is conditionally recommended over continuation of glucocorticoids for patients taking glucocorticoids to remain at target. Addition of/switching to DMARDs (with or without IA glucocorticoids) is conditionally recommended over use of IA glucocorticoids alone for patients taking DMARDs who are not at target. Table 8 continues on next page.
Patients treated with DMARDs who are not at target
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