Table 2. Turkish League Against Rheumatism 2018 update recommendations for the pharmacological management of rheumatoid arthritis.

	Overarching principles
A	In the management of RA patients, providing the best care should be targeted and the treatment should rely on a co-decision between the physician and the patient.
B	Treatment decision should be made considering disease activity, comorbidities, progression of the structural damage, and safety topics.
C	Rheumatologists and physical medicine and rehabilitation specialists are the primary experts to take care of RA patients
D	RA has high individual, medical, and societal costs. All these aspects should be taken into account by the specialist when treatment decisions are made.
	Recommendations
1	Treatment with DMARDs should be initiated soon after the RA diagnosis is made.
2	Treatment goal should be achieving sustained remission or low disease activity in all patients.
3	In case of active disease, patients should have frequent follow-ups (every one-three months). The treatment should be re-adjusted if clinical improvement cannot be obtained in three months or the treatment goal cannot be reached within six months.
4	Methotrexate should constitute a part of the first treatment regimen.
5	If MTX cannot be used because of contraindications or intolerance, LEF or SSZ should be started as a part of the first treatment regimen.
6	In the periods of csDMARD initiation or change, GCs should be considered for short-term use with different dose and administration routes; however, it should be tapered rapidly when the clinical condition permits.
7	If the treatment goal cannot be reached with the first treatment regimen, in the absence of poor prognostic factors, other csDMARDs should be initiated.
8	If the treatment goal cannot be reached with the first treatment regimen, in the presence of poor prognostic factors, a bDMARD or tsDMARD addition should be considered. Generally, bDMARD is the first treatment choice.
9	bDMARD and tsDMARDs should be used together with a csDMARD. For patients who cannot use csDMARDs along with these medications, IL-6 inhibitors or tsDMARDs may have beneficial effects over other bDMARDs.
10	In case of bDMARD or tsDMARD failure, treatment with another bDMARD or tsDMARD should be given. In case of one TNFi failure, another TNFi or medication with a different mechanism may be considered.
11	In case of persistent remission after tapering GCs in a patient using csDMARDs as comedication, dose reduction of bDMARDs may be considered.
12	In case of persistent remission after tapering bDMARDs, dose reduction of the csDMARD may be considered.
RA: Rheumatoid arthritis; DMARD: Disease modifying anti-rheumatic drug; MTX: Methotrexate; LEF: Leflunomide; csDMARD: Conventional synthetic disease modifying anti-rheumatic drug; GC: Glucocorticoid; bDMARD: Biologic disease modifying anti-rheumatic drug; targeted synthetic disease modifying anti-rheumatic drug; IL: Interleukin; TNFi: Tumor necrosis factor inhibitor.