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type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/advagg_css\/css__ce2QY63WIanKyr8eSq7eavr1XQRRmFD6ZSmwpyJi8lM__zXwFqpqmxrZOXXcd_TpBQpjuELbmIP9wBR5UuTDWAO4__YJWWMMdfCJuAFm5cUEp88OsodhO3ZA-2lzRfoBsSlk4.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\n            \u003Cp id=\u0022p-1\u0022\u003EThe first European League Against Rheumatism (EULAR) recommendations for the management of rheumatoid arthritis (RA) with synthetic and biologic disease-modifying antirheumatic drugs (DMARDs) were published in 2010 [Smolen JS et al. \u003Cem\u003EAnn Rheum Dis\u003C\/em\u003E 2010]. A task force proposed updated recommendations in April 2013. This article discusses the the 2013 preliminary recommendations. which are based on three systemic literature reviews on the following topics: 1) DMARDs; 2) biologic DMARDs; and 3) safety issues.\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003ERheumatology Guidelines\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ERheumatoid Arthritis\u003C\/li\u003E\u003C\/ul\u003E\u003Cul class=\u0022kwd-group clinical-trial\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003ERheumatology\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ERheumatology Guidelines\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ERheumatoid Arthritis\u003C\/li\u003E\u003C\/ul\u003E\u003Cp id=\u0022p-2\u0022\u003EThe first European League Against Rheumatism (EULAR) recommendations for the management of rheumatoid arthritis (RA) with synthetic and biologic disease-modifying antirheumatic drugs (DMARDs) were published in 2010 [Smolen JS et al. \u003Cem\u003EAnn Rheum Dis\u003C\/em\u003E 2010]. A task force led by Josef S. Smolen, MD, Medical University of Vienna and Hietzing Hospital, Vienna, Austria, proposed updated recommendations in April 2013. The task force included rheumatologists, patient representatives, an infectious disease specialist, and a health economist. The updated recommendations are intended for a large target audience of healthcare professionals, patients, rheumatology societies, hospital managers, health insurance representatives, and politicians.\u003C\/p\u003E\u003Cp id=\u0022p-3\u0022\u003EThe 2013 preliminary recommendations are based on three systemic literature reviews on the following topics: 1) DMARDs, including tofacitinib and glucocorticoids; 2) biologic DMARDs, including biosimilars; and 3) safety issues. At the final task force meeting on April 9, 2013, four breakout groups evaluated each of these topics.\u003C\/p\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-1\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EPRELIMINARY RECOMMENDATIONS\u003C\/h2\u003E\n         \u003Cp id=\u0022p-4\u0022\u003EThe 2013 recommendations include three overarching principles and 14 recommendations. The overarching principles are similar to those included in the 2010 recommendations (\u003Ca id=\u0022xref-table-wrap-1-1\u0022 class=\u0022xref-table\u0022 href=\u0022#T1\u0022\u003ETable 1\u003C\/a\u003E). Essentially, the task force recommended switching the order of principles A and B and slightly rewording principle C.\u003C\/p\u003E\n         \u003Cdiv id=\u0022T1\u0022 class=\u0022table pos-float\u0022\u003E\u003Cdiv class=\u0022table-inline\u0022\u003E\u003Cdiv class=\u0022callout\u0022\u003E\u003Cspan\u003EView this table:\u003C\/span\u003E\u003Cul class=\u0022callout-links\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022\/\u0022 class=\u0022table-expand-inline\u0022 data-table-url=\u0022\/highwire\/markup\/13844\/expansion?postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed\u0026amp;table-expand-inline=1\u0022 html=\u00221\u0022 fragment=\u0022#\u0022 external=\u00221\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView inline\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022\/highwire\/markup\/13844\/expansion?width=1000\u0026amp;height=500\u0026amp;iframe=true\u0026amp;postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media\u0022 class=\u0022colorbox colorbox-load table-expand-popup\u0022 rel=\u0022gallery-fragment-tables\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView popup\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/13844\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cdiv class=\u0022table-caption\u0022\u003E\u003Cspan class=\u0022table-label\u0022\u003ETable 1.\u003C\/span\u003E \n               \u003Cp id=\u0022p-5\u0022 class=\u0022first-child\u0022\u003EEULAR 2010 Overarching Principles for Treatment of Rheumatoid Arthritis\u003C\/p\u003E\n            \u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n         \u003Cp id=\u0022p-7\u0022\u003EThe 2010 recommendations are shown in \u003Ca id=\u0022xref-table-wrap-2-1\u0022 class=\u0022xref-table\u0022 href=\u0022#T2\u0022\u003ETable 2\u003C\/a\u003E for reference.\u003C\/p\u003E\n         \u003Cp id=\u0022p-8\u0022\u003EAmong the key preliminary changes, the task force proposed dividing the second 2010 guideline into two recommendations, with recommendation 2 reiterating that treatment should be aimed at reaching a target of remission or low disease activity in every patient. Prof. Smolen noted that remission should be defined according to the American College of Rheumatology Boolean-based definition or index-based definition using the simplified disease activity index and clinical disease activity index. If remission is not likely to be achieved, low disease activity may be used as the treatment target. Preliminary recommendation 3 clarifies when therapy should be adjusted, proposing that if the patient does not improve by 3 months after the start of treatment, or if the target has not been reached by 6 months, therapy should be adjusted. Injectable gold has been eliminated from the proposed recommendations due to limited use and lack of availability in some countries.\u003C\/p\u003E\n         \u003Cp id=\u0022p-9\u0022\u003EAnother key recommendation clarifies that in DMARD-na\u00efve patients, either conventional synthetic DMARD monotherapy or a combination of conventional synthetic DMARDs should be used, irrespective of the addition of glucocorticoids. The 2010 recommendation 5 stating that \u201csynthetic DMARD monotherapy rather than combination synthetic DMARD therapy may be used\u201d was not meant to imply that use of combination synthetic DMARDs was incorrect, but only that it was not needed, according to Prof. Smolen. The 2013 recommendation reiterates the evidence-based view that synthetic DMARD monotherapy is effective, while more explicitly endorsing combination synthetic DMARD therapy. A preference to use combination DMARDs is not stated because of possible limitations in trial designs and conflicting trial data. Prof. Smolen pointed out that the level of evidence for the first six preliminary recommendations is very high, with 87% to 100% agreement among task force members and strength of recommendation of 9.0 to 9.8.\u003C\/p\u003E\n         \u003Cp id=\u0022p-10\u0022\u003EThe updated recommendations give preference to low-dose glucocorticoids (\u226410 mg\/day) added to synthetic DMARDs over the \u201clow to moderately high doses\u201d recommended in 2010. The 2010 guidelines recommend biologic therapy with a tumor necrosis factor inhibitor combined with methotrexate (MTX) after insufficient response to MTX or other synthetic DMARDs; the 2013 preliminary recommendations add abatacept and tocilizumab (and under certain circumstances, rituximab) to the biologic therapy options. This addition was based on registry data and 5 years of experience with abatacept, tocilizumab, and rituximab showing no advantage for any agent as the first biologic therapy. The updated recommendations also state a preference for combining all biologics with MTX or other synthetic DMARDs. If monotherapy must be used, tocilizumab is recommended as the preferred agent. The level of evidence for the proposed recommendations 7 and 8 was high, with 73% to 100% agreement among task force members and strength of recommendation of 8.9 to 9.4.\u003C\/p\u003E\n         \u003Cp id=\u0022p-11\u0022\u003EThe task force proposed eliminating the 2010 recommendations 10, 11, and 14. The updated recommendation 11 is new, stating that therapy with tofacitinib may be considered after biologic treatment has failed. Although tofacitinib is not approved in the European Union, the task force decided to include it because the EULAR recommendations are not only for EU countries, and available evidence demonstrates its clinical, functional, and structural efficacy. Because some risks, such as herpes zoster infection, may be higher with tofacitinib than with biologics, the task force proposed that it should be used after at least one biologic therapy has failed, and, preferably, after two have failed. The level of evidence for recommendations 11 through 14 was high, with 90% to 100% agreement among task force members and strength of recommendation of 7.6 to 9.7.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-2\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003ESUMMARY OF PRELIMINARY 2013 RECOMMENDATIONS\u003C\/h2\u003E\n         \u003Cp id=\u0022p-12\u0022\u003ESynthetic DMARDs, including combination therapy, are still considered effective for first-line treatment of RA. All biologic agents are considered equally safe and effective for initial biologic therapy. A combination of biologic therapy and MTX is preferable to monotherapy when MTX monotherapy does not control disease activity. However, biologic agents should not be used for initial DMARD therapy, as a treat-to-target approach leads to similar outcomes. The treat-to-target strategy is based on tight control of disease activity by routine assessment and adjustment of treatment aimed at a predefined target [Vermeer M et al. \u003Cem\u003EArthritis Res Ther\u003C\/em\u003E 2012].\u003C\/p\u003E\n         \u003Cp id=\u0022p-13\u0022\u003EThe updated recommendations reflect evidence gathered on RA therapies since the publication of the 2010 recommendations. They clarify issues such as the use of combination conventional synthetic DMARDs in DMARD-na\u00efve patients and address the use of tofacitinib\u2014even though it is not approved for use in the European Union. These recommendations will allow clinicians and patients to make shared, evidence-based treatment decisions.\u003C\/p\u003E\n         \u003Cdiv id=\u0022T2\u0022 class=\u0022table pos-float\u0022\u003E\u003Cdiv class=\u0022table-inline\u0022\u003E\u003Cdiv class=\u0022callout\u0022\u003E\u003Cspan\u003EView this table:\u003C\/span\u003E\u003Cul class=\u0022callout-links\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022\/\u0022 class=\u0022table-expand-inline\u0022 data-table-url=\u0022\/highwire\/markup\/13845\/expansion?postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed\u0026amp;table-expand-inline=1\u0022 html=\u00221\u0022 fragment=\u0022#\u0022 external=\u00221\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView inline\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022\/highwire\/markup\/13845\/expansion?width=1000\u0026amp;height=500\u0026amp;iframe=true\u0026amp;postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media\u0022 class=\u0022colorbox colorbox-load table-expand-popup\u0022 rel=\u0022gallery-fragment-tables\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView popup\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/13845\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cdiv class=\u0022table-caption\u0022\u003E\u003Cspan class=\u0022table-label\u0022\u003ETable 2.\u003C\/span\u003E \n               \u003Cp id=\u0022p-14\u0022 class=\u0022first-child\u0022\u003EEULAR 2010 Rheumatoid Arthritis Recommendations\u003C\/p\u003E\n            \u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n      \u003C\/div\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2013 MD Conference Express\u00ae\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/13\/18\/26.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nzo5ld\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_tables.js?nzo5ld\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}