NICE says that the aim for treating RA should be to achieve a target of remission or low disease activity if remission cannot be achieved (‘treat-to-target’). This may involve trying different cDMARDs and biologics with different mechanisms in succession.6
In newly diagnosed RA, NICE recommends cDMARD monotherapy using oral methotrexate, leflunomide or sulfasalazine as a first-line treatment as soon as possible and ideally within three months of onset of persistent symptoms.
Hydroxychloroquine can be used as an alternative first-line treatment for mild RA or where the RA flares up and then subsides (palindromic disease).
Dosage can be escalated to see if there is a response. If swapping between cDMARDs or starting a new cDMARD, a glucocorticoid may be used as a short-term bridging treatment. If dose escalation of one drug is not achieving the treatment target, a second cDMARD can be tried in combination.
Biological and synthetic DMARDs may be considered for further management – NICE has published individual technological appraisals for the different drugs.
Glucocorticoids can be used short-term for managing flares to rapidly decrease inflammation. If RA is established, steroids should only be continued long-term after fully discussing the potential for long-term complications and all other treatment options (including biological and targeted synthetic DMARDs) have been offered.
NSAIDs and COX-II inhibitors may be used to help with pain and stiffness but should be used at the lowest effective dose for the shortest possible time, and with gastric protection using a proton-pump inhibitor (PPI).