Proposed RA Pointers: Maximize Methotrexate Earlier than Switching


New proposed tips for managing rheumatoid arthritis (RA) suggest that methotrexate (MTX) be used aggressively earlier than different remedy choices.

Dr Liana Fraenkel

Earlier tips, final up to date in 2015, had not ranked the order of the therapies, stated Liana Fraenkel, MD, MPH, principal investigator for the American School of Rheumatology’s (ACR’s) remedy tips.

“There is a sturdy emphasis on maximizing methotrexate utilizing numerous means earlier than switching to a biologic or JAK [Janus kinase] inhibitor,” she stated in a press convention at ACR Convergence 2020. The rules draft was developed collaboratively with clinicians, researchers, and sufferers. As well as, the authors performed a complete evaluate of the literature.

Fraenkel, an adjunct professor at Yale Faculty of Drugs in New Haven, Connecticut, stated the exception for maximizing MTX can be for sufferers with low illness exercise for whom therapies with different drugs, resembling hydroxychloroquine (HCQ) and sulfasalazine, are possible, she stated.

Cease Defaulting to Prednisone

One other advice urges in opposition to using prednisone as a default remedy.

“We must always actually be making an attempt to maximise disease-modifying antirheumatic medication [DMARDs] and attempt to push the needle away from utilizing prednisone as incessantly as we do,” she stated.

Fraenkel stated the panel wished to emphasise that “even decrease doses of prednisone may be dangerous.”

She famous that sufferers on the rules panel stated it is onerous to taper off prednisone.

Don Thomas, MD, who’s in personal rheumatology observe in Greenbelt, Maryland, informed Medscape Medical Information, “I like the rules.

“Most of my sufferers are usually not on steroids,” he stated, “which is a godsend due to the good therapies we have now.”

He stated he was glad to see assist for exhausting methotrexate choices first earlier than making an attempt new therapies.

“Too many people are usually not as aggressive as we needs to be with utilizing methotrexate initially,” he stated.

Particular Suggestions

Within the proposed tips, MTX alone is strongly beneficial over HCQ or sulfasalazine and is conditionally beneficial over a standard artificial DMARD twin or triple mixture. MTX alone can be conditionally beneficial over MTX together with a tumor necrosis issue (TNF) inhibitor and is strongly beneficial over MTX together with a non-TNF inhibitor, a biologic, or a focused artificial DMARD.

For sufferers with low illness exercise who haven’t taken DMARDs, HCQ is beneficial over different typical artificial DMARDs. Sulfasalazine is beneficial over MTX, and MTX is beneficial over leflunomide.

For preliminary remedy, oral MTX is conditionally beneficial over subcutaneous administration. For sufferers who are usually not tolerating the oral model, “suggest split-dose or subcutaneous or rising folic acid over switching to a brand new DMARD,” she stated.

Fraenkel stated the oral advice was primarily based largely on affected person choice.

Use of Glucocorticoids

For sufferers who want glucocorticoids to stay at goal, including or switching DMARDs is beneficial over persevering with glucocorticoids, the rules point out.

“For sufferers on DMARDs and never at goal, including or switching DMARDs with or with out using intraarticular glucocorticoids is conditionally beneficial over using intraarticular glucocorticoids alone,” the proposed tips advise.


Tapering ought to solely be thought-about for sufferers “who’ve been at goal for a minimum of 6 months,” she stated. “In these sufferers, continuation of all DMARDs at their present dose is conditionally beneficial over any dose discount.”

Dose discount is beneficial over gradual discontinuation, and gradual discontinuation is beneficial over abruptly stopping.

Fraenkel acknowledged that the extent of proof is low to very low for lots of the suggestions (solely 7 of 44 suggestions have been categorized as sturdy), which, she stated, underscores the significance of shared choice making for RA.

She added, “We actually want trials to deal with clinically essential questions pushed by sufferers and never merely pushed by [having] a brand new molecule to check.”

ACR says the ultimate model of the proposed tips is predicted to be concurrently revealed in Arthritis Care and Analysis and Arthritis and Rheumatology by the tip of the 12 months.

These tips are targeted on pharmacologic brokers. Separate ACR tips will tackle nonpharmacologic administration of RA and vaccine suggestions for inflammatory illness.

Fraenkel and Thomas have disclosed no related monetary relationships.

American School of Rheumatology (ACR) 2020 Annual Assembly: Summary scientific session 5MO18. Introduced November 11, 2020.

Marcia Frellick is a contract journalist primarily based in Chicago. She has beforehand written for the Chicago Tribune and and was an editor on the Chicago Solar-Instances, the Cincinnati Enquirer, and the St. Cloud (Minnesota) Instances. Observe her on Twitter at @mfrellick.

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