Josef S Smolen 1 , 2 , Robert Landewé 3 , Ferdinand C Breedveld 4 , Maxime Dougados 5 , Paul Emery 6 , Cecile Gaujoux-Viala 5 , 7 , Simone Gorter 3 , Rachel Knevel 4 , Jackie Nam 6 , Monika Schoels 2 , Daniel Aletaha 1 , Maya Buch 6 , Laure Gossec 5 , Tom Huizinga 4 , Johannes W J W Bijlsma 8 , Gerd Burmester 9 , Bernard Combe 10 , Maurizio Cutolo 11 , Cem Gabay 12 , Juan Gomez-Reino 13 , Marios Kouloumas 14 , Tore K Kvien 15 , Emilio Martin-Mola 16 , Iain McInnes 17 , Karel Pavelka 18 , Piet van Riel 19 , Marieke Scholte 14 , David L Scott 20 , Tuulikki Sokka 21 , Guido Valesini 22 , Ronald van Vollenhoven 23 , Kevin L Winthrop 24 , John Wong 25 , Angela Zink 26 , Désirée van der Heijde 4
1 June 2010
Treatment of rheumatoid arthritis (RA) may differ among rheumatologists and currently, clear and consensual international recommendations on RA treatment are not available. In this paper recommendations for the treatment of RA with synthetic and biological disease-modifying antirheumatic drugs (DMARDs) and glucocorticoids (GCs) that also account for strategic algorithms and deal with economic aspects, are described. The recommendations are based on evidence from five systematic literature reviews (SLRs) performed for synthetic DMARDs, biological DMARDs, GCs, treatment strategies and economic issues. The SLR-derived evidence was discussed and summarised as an expert opinion in the course of a Delphi-like process. Levels of evidence, strength of recommendations and levels of agreement were derived. Fifteen recommendations were developed covering an area from general aspects such as remission/low disease activity as treatment aim via the preference for methotrexate monotherapy with or without GCs vis-à-vis combination of synthetic DMARDs to the use of biological agents mainly in patients for whom synthetic DMARDs and tumour necrosis factor inhibitors had failed. Cost effectiveness of the treatments was additionally examined. These recommendations are intended to inform rheumatologists, patients and other stakeholders about a European consensus on the management of RA with DMARDs and GCs as well as strategies to reach optimal outcomes of RA, based on evidence and expert opinion.