Table VI.
RA disease duration | RA disease activity | Previous treatments failed | Recommendation |
---|---|---|---|
<6 months | High for 3–6 months | – | TNF antagonist plus MTX |
High for <3 months, plus features of poor prognosis,a and no cost or insurance coverage limitations | |||
| |||
≥6 months | High | MTX monotherapy | TNF antagonist |
Moderate, plus features of poor prognosis | |||
| |||
≥6 months | High | MTX combination therapy | With features of poor prognosis: TNF antagonists, abatacept, or rituximab (the latter only if disease activity is high) |
Moderate | Sequential administration of other nonbiologic DMARDs | ||
Without features of poor prognosis: nonbiologic DMARD or TNF-antagonist |
Features of poor prognosis include functional limitation (defined using standard measurement scales such as Health Assessment Questionnaire score), extra-articular disease (eg, presence of rheumatoid nodules, secondary Sjögren’s syndrome, RA vasculitis, Felty’s syndrome, and RA lung disease), rheumatoid factor positivity, positive anti-cyclic citrullinated peptide antibodies, or bony erosions on radiography.
ACR = American College of Rheumatology; DMARDs = disease-modifying anti-rheumatic drugs; MTX = methotrexate; RA = rheumatoid arthritis; TNF = tumor necrosis factor.