Treat to target in Rheumatoid Arthritis series – 1

Boolean based remission criteria according to ACR/EULAR criteria include the following: Tender joint count of 1 or less, Swollen joint count of 1 or less, CRP level of 1 mg/dL or lower, and Patient global assessment of 1 or less (on a 0-10 scale).

Reference –

• Bykerk VP, Massarotti EM. The new ACR/EULAR remission criteria: rationale for developing new criteria for remission. Rheumatology (Oxford). 2012;51 Suppl 6:vi16-vi20. doi:10.1093/rheumatology/kes281.
• Anderson J, Caplan L, Yazdany J, et al. Rheumatoid arthritis disease activity measures: American College of Rheumatology recommendations for use in clinical practice. Arthritis Care Res (Hoboken). 2012;64(5):640-647. doi:10.1002/acr.21649.

Because it is better tolerated and has a better risk profile in people with RA, hydroxychloroquine is conditionally recommended above other csDMARDs. As sulfasalazine is less immunosuppressive than methotrexate, the patient panel believes that many patients with modest disease activity would prefer to avoid the adverse effects of methotrexate. The recommendations are conditional since methotrexate may be the recommended initial therapy in patients with poor prognostic characteristics and those at the higher end of the low disease activity spectrum. For its higher dosing flexibility and lower cost, methotrexate is preferred over leflunomide.

Reference –

• Fraenkel L, Bathon JM, England BR, St. Clair EW, Arayssi T, Carandang K, Deane KD, Genovese M, Huston KK, Kerr G, Kremer J. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis & Rheumatology. 2021 Jul;73(7):1108-23.

Reference

• Singh JA, Saag KG, Bridges SL Jr, et al. 2015 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis. Arthritis Care Res (Hoboken). 2016;68(1):1-25.
• Einarsson JT, Willim M, Ernestam S, Saxne T, Geborek P, Kapetanovic MC. Prevalence of sustained remission in rheumatoid arthritis: impact of criteria sets and disease duration, a Nationwide Study in Sweden. Rheumatology (Oxford). 2019;58(2):227-236.

The recommendation is conditional because the voting panel believes that certain patients with ongoing disease activity despite treatment with a single csDMARD will choose combination treatment for a faster response.

Reference –

• Fraenkel L, Bathon JM, England BR, St. Clair EW, Arayssi T, Carandang K, Deane KD, Genovese M, Huston KK, Kerr G, Kremer J. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis & Rheumatology. 2021 Jul;73(7):1108-23.