Monday, July 1, 2013

New Rheumatoid Arthritis Guidelines at the EULAR 2013 Meeting

Too bad, I’ve missed the session, in which the new guidelines were presented. The guidelines will be published soon to replace the 2010 guidelines. I’ll look through the guidelines as soon as possible, but can rely for the time being on an article by Alice Goodman.

According to Josef Smolen, MD, "the 2013 EULAR guidelines will avoid the overtreatment of 20% to 30% of patients with rheumatoid arthritis".
Tocilizumab will get special attention as monotherapy, while TNF-inhibitors and other biologics should be used in combination with methotrexate.
Methotrexate is the first line drug of choice. One can substitute MTX for leflunomide or sulphasalazine, if MTX isn’t tolerated. Gold isn’t available at all places and is therefore omitted, but still has a mention in the German guidelines for instance.
After DMARD failure (not reaching the target) therapies should be stratified to DMARDs in combination or biologics according to individual prognosis.
Biosimilars are mentioned in the text and we’ll have to wait and see, what Celltrion and Hospira are going to do. Inflectra and Remsima have a positive opinion in the EU, but EMEA hasn’t approved yet. “Johnson & Johnson and partner Merck & Co. may initiate a patent infringement case against Celltrion and Hospira if they launch their products in Europe.” Link:  
Tofacitinib already has a place in the EULAR guidelines, but EMEA isn’t near approval. I think that including tofacitinib is premature, but we’ll have to look at the text, when it will have been published. Needless to say, but I say it: I’m also desperately waiting for tofacitinib’s approval because we already have patients, who need a new drug as they have been through with all the established drugs.
Initial low dose glucocorticoids lead to better result. High dosage and long duration on steroids should be avoided.

All and all, it’s a good idea to update guidelines as quickly as science changes, but the guidelines shouldn’t run ahead.

PS. Consider my word preliminary as I wait for the full text of the EULAR Rheumatoid Arthritis Guidelines to be released.


  1. Would anyone care to respond to the negative press methotrexate has... Another form of chemo... ect,ect.

    1. This is the 3rd time I try to respond.
      Methotrexate (MTX) had been developed as a chemotherapy against cancer. MTX is used in rheumatology in smaller dosages. Side effects are well known and monitored. Which side effect has been mentioned in the article you've read?