Rheumatoid Arthritis Treatments

Guidelines for Non-biologic and Biologic DMARD Use in Rheumatoid Arthritis

X-ray showing rheumatoid arthritis in hands
X-ray showing rheumatoid arthritis in hands. RNHRD NHS Trust / Getty Images

Rheumatoid arthritis treatments include medication options that have expanded over the last decade. The American College of Rheumatology (ACR) has released its 2008 guidelines for rheumatoid arthritis treatments -- an update of the 2002 guidelines. The 2008 recommendations focus on the use of non-biologic DMARDs (disease-modifying anti-rheumatic drugs) and biologic DMARDs to treat the disease.

The guidelines were developed by an expert panel of doctors, researchers, and patient representatives following extensive review of scientific evidence related to non-biologic and biologic treatments.

The recommendations were primarily designed for rheumatologists but they are also of interest to patients, especially those who want to learn what is usually involved in choosing an optimal treatment for rheumatoid arthritis.

The recommendations are not to be used like a cookbook, or to replace a doctor's judgment regarding an individual patient. The recommendations do reflect how non-biologic and biologic DMARDs would typically be used after considering:

  • how long a patient has had rheumatoid arthritis
  • the severity of rheumatoid arthritis symptoms
  • potential for side effects
  • tuberculosis screening (required before starting biologic DMARDs)
  • cost of treatment
  • patient preference regarding treatment options

The 2008 ACR Recommendations for Rheumatoid Arthritis Treatments

  • Initiating treatment with methotrexate or Arava (leflunomide) was recommended for most rheumatoid arthritis patients.
  • Methotrexate plus Plaquenil (hydroxychloroquine) was recommended for rheumatoid arthritis patients with moderate to high disease activity.
  • The combination of three DMARDs (methotrexate plus hydroxychloroquine plus sulfasalazine) was recommended for patients with moderate to high levels of disease activity and factors that suggest a poor prognosis (predicted course of the disease).
  • Treatment with a TNF blocker -- Enbrel (etanercept), Remicade (infliximab), or Humira (adalimumab) -- plus methotrexate is recommended for patients with early rheumatoid arthritis (symptoms for less than 3 months) only when there is high disease activity and the patient has never been treated with a DMARD.
  • For rheumatoid arthritis patients with moderate to long disease duration, TNF blockers were recommended for those who failed to get a satisfactory response from methotrexate therapy.
  • Orencia (abatacept) and Rituxan (rituximab) should be reserved for patients with at least moderate disease activity and a poor disease prognosis following treatment with methotrexate or other DMARDs that led to an inadequate treatment response.
  • Treatment with methotrexate, Arava, or biologic DMARDs (Enbrel, Remicade, Humira, Orencia, or Rituxan) should not be started or resumed in patients with an active bacterial infection, active herpes-zoster viral infection, active or latent tuberculosis, or acute or chronic hepatitis B or hepatitis C.
  • TNF blockers should not be prescribed to rheumatoid arthritis patients with a history of heart failure, lymphoma, multiple sclerosis, or other demyelinating disorders.
  • Methotrexate, Arava, or minocycline should not be started or resumed for the treatment of rheumatoid arthritis in patients planning for pregnancy or throughout pregnancy and breastfeeding.

    The ACR expects to regularly update the recommendations as new scientific evidence becomes available. To reiterate an important point, these are only recommendations. Individual patients may require a different plan.


    American College of Rheumatology 2008 Recommendations for the Use of Non-biologic and Biologic Disease Modifying Anti-rheumatic Drugs in Rheumatoid Arthritis. Saag KG et al. Arthritis and Rheumatism.

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