American College of Rheumatology
View all recommendations from this societyReleased February 21, 2013
Don’t prescribe biologics for rheumatoid arthritis before a trial of methotrexate (or other conventional non-biologic DMARDs).
High quality evidence suggests that methotrexate and other conventional non-biologic disease modifying antirheumatic drugs (DMARD) are effective in many patients with rheumatoid arthritis (RA). Initial therapy for RA should be a conventional non-biologic DMARDs unless these are contraindicated. If a patient has had an inadequate response to methotrexate with or without other non-biologic DMARDs during an initial 3-month trial, then biologic therapy can be considered. Exceptions include patients with high disease activity and poor prognostic features (functional limitations, disease outside the joints, seropositivity or bony damage), where biologic therapy may be appropriate first-line treatment.
These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician.
How The List Was Created
The American College of Rheumatology (ACR) established a Top 5 Task Force to oversee the creation of its recommendations. As part of this group’s work, a multistage process combining consensus methodology and literature reviews was used to arrive at the final recommendations. Items were generated by a group of practicing rheumatologists in diverse clinical settings using the Delphi method. Recommendations with high content agreement and perceived prevalence advanced to a survey of ACR members, who comprise more than 90% of the U.S. rheumatology workforce. Based on member input related to content agreement, impact and item ranking, candidate items advanced to literature review. The Top 5 Task Force discussed the items in light of their relevance to rheumatology, level of evidence to support their inclusion, and the member survey results, and drafted the final rheumatology Top 5 list. The list was reviewed by a sample of patients with rheumatic disease and approved by the ACR Board of Directors. For further details regarding these methods, please see the manuscript published in Arthritis Care & Research at www.rheumatology.org/FiveThings.
ACR’s disclosure and conflict of interest policy can be found at www.rheumatology.org.
Sources
Singh JA, Furst DE, Bharat A, Curtis JR, Kavanaugh AF, Kremer JM, Moreland LM, O’Dell J, Winthrop KL, Beukelman T, Bridges SL, Chatham WW, Paulus HE, Suarez-Almazor M, Bombardier C, Dougados M, Khanna D, King CM, Leong AL, Matteson EL, Schousboe JT, Moynihan E, Kolba KS, Jain A, Volkmann ER, Agrawal H, Bae S, Mudano AS, Patkar NM, Saag KG. 2012 update of the 2008 American College of Rheumatology recommendations for the use of disease-modifying antirheumatic drugs and biologic agents in the treatment of rheumatoid arthritis. Arthritis Care Res (Hoboken);64(5):625-39.
Smolen JS, Landewe R, Breedveld FC, Dougados M, Emery P, Gaujoux-Viala C, Gorter S, Knevel R, Nam J, Schoels M, Aletaha D, Buch M, Gossec L, Huizinga T, Bijlsma JW, Burmester G, Combe B, Cutolo M, Gabay C, Gomez-Reino J, Kouloumas M, Kvien TK, Martin-Mola E, McInnes I, Pavelka K, van Riel P, Scholte M, Scott DL, Sokka T, Valesini G, van Vollenhove R, Winthrop KL, Wong J, Zink A, van der Heijde D. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs. Ann Rheum Dis;69(6):964-75.
