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


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


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