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Recommendations of the Czech Society for Rheumatology for the treatment of rheumatoid arthritis


Authors: K. Pavelka;  J. Vencovský
Authors‘ workplace: Revmatologický ústav, Praha
Published in: Čes. Revmatol., 18, 2010, No. 4, p. 182-191.
Category: Overview Reports

Overview

In the last decade, there has been a significant progress in the treatment of rheumatoid arthritis (RA). This development is based on the introduction of new synthetic and biological drugs in the treatment of RA, and furthermore, improved and regular evaluation of disease activity in RA using composite scoring markers (e.g. DAS 28). Improved methods of evaluation of negative prognostic factors as well as formulation of new management strategies, such as the “Treat to target” concept are important developments. Thus the Czech Society of Rheumatology issues new recommendations reflecting these changes better than the last recommendations from 2007. Treatment of patients with active RA is based on the application of disease modifying anti-rheumatic drugs (DMARDs); with methotrexate being the drug of first choice with the best risk/benefit ratio. The treatment should be initiated at a dose of 10–15 mg per week. In case of insufficient effect, the dose should be increased to 25–30 mg weekly or the oral form should be switched to subcutaneous application. In case of insufficient efficacy or intolerance to methotrexate, there is evidence supporting use of leflunomide, sulfasalazine, and gold salts. Other DMARDs are used relatively rarely. In case of insufficient response to methotrexate therapy, methotrexate can be combined with leflunomide and cyclosporine, but this procedure should be reserved for patients who do not have negative prognostic indicators. In case of persistent high activity, short-term medium and high doses of glucocorticoids can be used. In patients with the presence of such indicators and insufficient efficacy of methotrexate, a biological agent should be added to methotrexate, preferably an inhibitor of tumor necrosis factor α (anti-TNF), namely infliximab, etanercept, adalimumab, certolizumab or golimumab. Biological therapy is indicated in case of methotrexate or other DMARD failure defined as DAS 28 higher than 3.9. The goal of a biological treatment, namely the state of remission, should be achieved within 3–6 months (DAS 28 <2.6). For long-term RA, achieving the state of low disease activity (DAS 28 <3.2) can be an alternative treatment target. In case of primary or secondary anti-TNF failure, the biological agent should be switched to either another anti-TNF agent or a biological drug with a different mechanism of action (abatacept, rituximab and tocilizumab). In patients who meet the criteria of remission during two consecutive visits, tapering of the treatment can be considered. Glucocorticoids should be slowly tapered as the first, followed by tapering of the biological drug. There is evidence supporting the benefit of long-term continuation of synthetic DMARD treatment.

Key words:
rheumatoid arthritis, treatment, biological therapy


Sources

1. Pincus T, Callahan LF, Sale WG, et al. Severe functional declines, work disability and increased mortality in seventy-five rheumatoid arthritis patiens studied over nine years. Arthritis Rheum 1984; 27: 864-872.

2. Aletaha D, Neogi T, Silman AJ, Funovits J, Felson DT, et al. 2010 Rheumatoid Arthritis Classification Criteria An American College of Rheumatology/European League Against Rheumatism Collaborative Initiative. Ann Rheum Dis 2010; 69: 1580-1588.

3. Combe B, Dougados M, Goupile P, et al. Prognostic factors for radiographic damage in early rheumatoid arthritis: a multiparameter prospective study. Arthritis Rheum 2001; 44: 1736-1743.

4. Smolen J, van der Heijde D, St Clair EW, et al. Predictors of joint damage in patiens with early rheumatoid arthritis treated with high-dose methotrexate without or with concomitant infliximab. Results from the ASPIRE trial. Arthritis Rheum 2006; 54: 702-710.

5. Van Gestel AM, Prevoo MLL, van Hof M, et al. Development and validation of ACR and WHO/ILAR criteria. Arthritis Rheum 1996; 39: 34-40.

6. Smolen J, Breedveld FC, Schiff MH, et al. A simplified disease activity index for rheumatoid arthritis for use in clinical practise. Rheumatology (Oxford) 2003; 42: 244-257.

7. Aletaha D, Smolen JS. The simplified Disease Activity Index (CDAI) to monitor patiens in standard clinical care. Best Pract Res Clin Rheumatol 2007; 21: 663-75.

8. Pavelka K, Gatterová J, Tegzová D, et al. Radiographic progression of rheumatoid arthritis patiens from Czech National Registry receiving infliximab treatment. Clin Exp Rheum 2007; 25: 451-454.

9. Ramey DR, Raynalud JP, Fries JF. The health assessment questionnaire1992: status and review. Arthritis Care Res 1992; 5: 119-129.

10. Sharp JT, Young DY, Bluem GB, et al. How many joints in the hands and wrists should be included in a score of radiologic abnormalities used to assess rheumatoid arthritis. Arthritis Rheum 1985; 28: 1326-1385.

11. Jong Z, et al. Long-term follow-up a high-intensity exercise program in patients with rheumatoid arthritis. Clin Rheumatol 2009; 28: 663-671.

12. Hirvonen HE, Mikkelsson MK, Kautiainen H, et al. Effectiveness of different cryotherapies on pain and disease activity in active rheumatoid arthritis. A randomised single blinded controlled trial. Clin Exp Rheumatol 2006; 24(3): 295-301.

13. Visser K, Katchmart W, Loza E, et al. Multinational evidence based recommendations for the use of methotrexate in rheumatic disorders with a focus on rheumatoid arthritis: integrating systematic literature research and expert opinion of a broad international panel of rheumatologists in the 3E initiative. Ann Rheum Dis 2009; 68: 1086-1093.

14. Visser K, van der Heijde D. Optimal dosage and route of administration of methotrexate in rheumatoid arthritis: a systematic review of the literature. Ann Rheum Dis 2009; 68: 1094-1099.

15. Braun J, Flaxenberg P, Waehrisch J, et al. Comparison of the clinical efficacy and safety of subcutaneous methotrexate in patiens with active rheumatoid arthritis. Arthritis Rheum 2008; 58: 73-81.

16. van Ede AE, Laan RF, Rood MJ, et al. Effect of folic and folinic acid supplementation on the toxicity and efficacy of methotrexate in rheumatoid arthritis: a forty – eight week, multicenter, randomized, double-blind, placebo controlled study. Arthritis Rheum 2001; 44: 1515-1524.

17. Smolen JS, Kalden J, Scott DL, et al. Efficacy and safety of leflunomide compared with placebo and sulphasalazine in active rheumatoid arthritis: a double blind, randomized, multicenter study. Lancet 1999; 353: 259-266.

18. Plosker GL, Croom KF. Sulfasalazine: a review of its use in the management of rheumatoid arthritis. Drugs 2005; 65: 1815-1849.

19. Strand V, Cohen S, Schiff M, et al. Treatment of active rheumatoid arthritis with leflunomide compared with placebo and methotrexate. Arch Intern Med 1999; 159: 242-2550.

20. Weinblatt ME, Reda D, Henderson W, et al. Sulfasalazine treatment for rheumatoid arthritis: a metaanalysis of 15 randomized trials. J Rheumatol 1999; 26: 2123-2130.

21. Suarez-Almazor ME, Belseck F, Shea B, et al. Antimalarials for treating rheumatoid arthritis. Cochrane Database Syst Rev 2000; 4: CD 000959.

22. O Dell J. Treatment of rheumatoid arthritis with methotrexate alone, sulfasalazine and hydroxychlorochine, or combination of all three medications. N Engl J Med 1996; 334: 1287-1291.

23. Rau R, Herborn G, Menninger H, et al. Radiographic outcome after three years of patiens with early erosive rheumatoid arthritis treated with intramuscular methotrexate or parenteral gold. Extension of a one-year double blind study in 174 patients. Rheumatology (Oxford) 2002; 41: 196-204.

24. Tugwell P, Pincus T, Yocum D, et al. Combination therapy with cyklosporine and methotrexate in severe rheumatoid arthritis. Engl J Med 1995; 333: 137-141.

25. O Dell JR, Leff R, Paulsen G, et al. Treatment of rheumatoid arthritis with methotrexate and hydoxychloroquine, methotrexate and sulsalazine, or combination of the three medications: results of a two –year randomized, double blind, placebo controlled trial. Arthritis Rheum 2002; 46.1164-70.

26. Mottonen T, Hannonen P, Leirisalo-Repo M, et al. Comparison therapy with single-drug therapy in early rheumatoid arthritis: a randomized trial. Lancet 1999; 353: 1568-73.

27. Calguneri M, Pay S, Caliskaner Z, et al. Combination therapy versus monotherapy for the treatment of patients with rheumatoid arthritis. Clin Exp Rheumatol 1999; 17: 699-704.

28. Kremer JM, Genovese MC, Cannon GW, et al. Concomitant leflunomide therapy in patiens with active rheumatoid arthritis despite stable doses of methotrexate: randomized, double blind, placebo controlled trial. Ann Intern Med 2002; 137: 726-33.

29. Boers M, Verhoeven AC, Markusse HM, et al. Randomised comparison of combined step-down prednisolone, methotrexate and sulphasalazine with sulphasalazine alone in early rheumatoid arthritis: a randomised trial. Lancet 1997; 350: 309-318.

30. Smolen J, Aletaha D, Keystone E. Superior efficacy of combination therapy for rheumatoid arthritis. Fact or Fiction. Arthritis Rheum 2005; 52: 2975-2083.

31. Šedová L, Štolfa J, Horák P, Pavelka K. Doporučení České revmatologické společnosti pro monitorování bezpečnosti léčby revmatoidní artritidy. Čes Revmatol 2009; 1(17): 4-15.

32. Kirwan JR. The effect of glucocorticoids in joint destruction in rheumatoid arthritis. N Engl J Med 1995; 333: 142-146.

33. Nam JL, Winthrop KL, van Vollenhoven, et al. Current evidence for managment of rheumatoid arthritis with biological disease-modifying antirheumatic drugs: a systematic literature review informing the EULAR recommendations for the managment of RA. Ann Rheum Dis 2010; 69: 976-986.

34. Smolen JS, Landewe R, Breedveld FC, et al. EULAR recommendations for the managment of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs. Ann Rheum Dis 2010; 69: 964-975.

35. Maini RN, Taylor PC, Szechinski J, et al. Double blind randomized conrtolled clinical trial of the interleukin 6 receptor antagonist, tocilizumab in European patiens with rheumatoid arthritis who had an incomplete response to methotrexate. Arthritis Rheum 2006; 54: 2817-29.

36. Edwards JC, Sczepanski L, Schechinski J, et al. Efficacy of B cell targeted therapy with rituximab in patiens with rheumatoid arthritis. N Engl J Med 2004; 350: 2572-81.

37. Furst D, Keystone EC, Braun J, et al. Updated consensus statement on biological agents for treatment of rheumatic diseases. Ann Rheum Dis 2010, 69 (Suppl 1): 2-29.

38. Bečvář R, Vencovský J, Němec P, et al. Doporučení České revmatologické společnosti pro léčbu revmatoidní artritidy. Vnitřní Lék 2008; 54: 84-99.

39. Smolen J, Aletaha D, Bjilsma JW, et al. Treating rheumatoid arthritis to target: recommenadations of an international task force. Ann Rheum Dis onlin, 2010; 69: 631-7.

40. Klareskog L, van der Heijde D, de Jager JP, et al. Therapeutic effect of the combination of etanercept and methotrexate compared with each treatment alone in patiens with rheumatoid arthritis: double blind - randomised controlled trial. Lancet 2004; 363: 675-81.

41. Breedveld F, Weisman MH, Kavanaugh, et al. The Premier study: a multicenter, randomized, double blind clinical trial of combination therapy with adalimumab plus methotrexate versus methotrexate alone or adalimumab alone in patiens with early, aggressive rheumatoid arthritis who had not previous methotrexate treatment. Arthritis Rheum 2006; 54: 26-37.

42. Jones G, Sebba A, Gu J, et al. Comparison of tocilizumab monotherapy versus methotrexate monotherapy in patiens with moderate to severe rheumatoid arthritis. The AMBITION study. Ann Rheum Dis 2010; 69: 88-96.

43. Westhovens R, Robles M, Ximenes AC, et al. Clinical efficacy and safety of abatacept in methotrexate naive patiens with early rheumatoid arthritis and poor prognostic factors. Ann Rheum Dis 2009; 68: 1870-1877.

44. Brocq O, Millassean E, Albert CH, et al. Effect of discontinuity TNFα antagonist therapy in patients with remission of rheumatoid arthritis. Joint Bone Spine 2009; 76: 350-355.

45. Ten Wolde S, Stermands J, Breedveld F, et al. Effect of resumption of second line drugs in patients with rheumatoid arthritis that flared up after treatment discombination. Ann Rheum Dis 1997; 56: 235-9.

46. Carmona L, Oriz A, Sabad MA, et al. How good is to switch between biologics?A systematic review of the literature. Acta Reumatol Port 2007; 32: 113-28.

47. Smolen JS, Kay J, Doyle MK, et al. Golimumab in patiens with active rheumatoid arthritis after treatment with tumour necrosis factor alfa inhibitors (GO-AFTER study) a multicentre, randomised, double blind, placebo controlled phase III.trial. Lancet 2009; 374: 210-21.

48. Cohen SB, Emery P, Greenwald MW, et al. Rituximab for rheumatoid arthritis refractory to anti tumor necrosis factor therapy: results of a multicenter,randomized, double blind, placebo controlled phase III trial evaluating primary efficacy and safety at twenty four weeks. Arthritis Rheum 2006; 64: 2793-806.

49. Genovese MC, Becker JC, Schiff M, et al. Abatacept for rheumatoid arthritis refractory to tumor necrosis factor alfa inhibition. N Engl J Med 2005; 353: 1114-23.

50. Emery P, Keystone E, Tony HP, et al. IL-6 receptor inhibition with tocilizumab improves treatment outcomes in patiens with rheumatoid arthritis refractory to anti tumor necrosis factors biologicals „results from a 24 week multicentre randomised, placebo controlled trial. Ann Rheum Dis 2008; 67: 1516-23.

51. Finckh A, Ciurea A, Brulhart L, et al. Which subgroup of rheumatoid arthritis patients benefits from switching to rituximab versus alternative anti-TNF agents after previous failure to anti-TNF agent? Ann Rheum Dis 2009; 2010; 69: 387-93.

Labels
Dermatology & STDs Paediatric rheumatology Rheumatology
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