EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs.

Abstract

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.

Full text

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ABSTRACT
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 fi ve 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.
INTRODUCTION
The management of rheumatoid arthritis (RA)
rests on several principles. Drug treatment, which
comprises disease-modifying antirheumatic drugs
(DMARDs), but also non-steroidal anti-infl am-
matory drugs and glucocorticoids (GCs), as well
as non-pharmacological measures, such as physi-
cal, occupational and psychological therapeutic
approaches, together may lead to therapeutic suc-
cess. However, the mainstay of RA treatment is the
application of DMARDs. It is DMARD treatment,
especially, which has undergone dramatic changes
EULAR recommendations for the management of
rheumatoid arthritis with synthetic and biological
disease-modifying antirheumatic drugs
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 Heijde4
For numbered affi liations see
end of the article
Correspondence to
Professor Josef S Smolen,
Division of Rheumatology,
Department of Medicine 3,
Medical University of Vienna,
Waehringer Guertel 18-20,
A-1090 Vienna, Austria;
josef.smolen@wienkav.at or
josef.smolen@meduniwien.
ac.at
Accepted 3 February 2010
JSS and RL are joint fi rst
authors.
during the past decade, providing previously unfore-
seen therapeutic dimensions. New and highly
effective DMARDs have continued to emerge
until the most recent years—in particular, biologi-
cal agents which target tumour necrosis factor, the
interleukin 1 (IL-1) receptor, the IL-6 receptor, B
lymphocytes and T-cell costimulation.1 In addition,
a chemical DMARD, lefl unomide, has become
available and compounds which have been in use
for many decades, such as methotrexate (MTX)
and sulfasalazine (SSZ), as well as GCs, have been
re-examined in order to achieve better effi cacy.
For example, the use of high dose MTX2 and the
disease-modifying effects of GCs, especially when
combined with traditional DMARDs,3–7 are now
well established. Furthermore, treatment strategies
have changed during this period, initially by calling
for early referral and early institution of DMARD
treatment on the basis of respective evidence of
clinical effi cacy,8–10 and later by showing that tight
control using composite measures of disease activ-
ity and appropriate switching of drug treatment are
highly effi cacious approaches.11–14
While all these data of clinical and observational
trials on drugs and strategies have been highly
enlightening, patients and rheumatologists are cur-
rently overwhelmed by this information which
does not always allow one to decide easily and
conclusively which path to follow when initiating
or changing therapeutic strategies in patients with
RA. Indeed, some inconsistencies in therapeutic
targets and strategies among rheumatologists have
been recognised in a survey performed at a recent
annual European Congress of Rheumatology.15
These inconsistencies may be partly based on
differences in attitudes among doctors caring for
patients with RA, settings (academic centres vs pri-
vate practice), patient preferences and reimburse-
ment policies. Information on the current state of
evidence for the effi cacy of different agents or ther-
apeutic strategies may also not always be regarded
as suffi ciently complete or available.
Along these lines, the European League Against
Rheumatism (EULAR) has recently formulated
major objectives, which among other aspects
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specify that “by 2012, EULAR will have provided standards of
care and foster access to optimal care of people with musculo-
skeletal conditions in Europe”.16 Since disease modifi cation con-
stitutes the most important therapeutic intervention in RA, it
was the objective of this EULAR Task Force to fi nd a consensus
on recommendations for the management of RA with synthetic
and biological DMARDs.
METHODS
The task force aimed at aggregating available information on
disease modifi cation in RA into practical recommendations.
The basis of the activities of the task force were the EULAR
standardised operating procedures for the development of rec-
ommendations,17 which suggest the institution of an expert
committee in charge of consensus fi nding on the basis of evi-
dence provided by a systematic literature review (SLR) and
expert opinion. The task of developing management recom-
mendations for RA was regarded as large and therefore war-
ranted division of the topic into fi ve main areas: (a) synthetic
DMARDs as monotherapy or in combination without GCs; (b)
GCs alone and in combination with synthetic DMARD(s); (c)
biological DMARDs; (d) treatment strategies; (e) economic
issues. The last aspect was deemed important to understand
the cost implications of treating RA by retrieving the exist-
ing evidence; the fourth area was intended to look at the best
approaches to attain the therapeutic goals, defi ne the term
‘strategy’ as a long-term plan of action to achieve that goal; and,
most importantly, the fi rst three areas were related to the evi-
dence available for the effi cacy, safety and monitoring of cur-
rently employed drugs.
The recommendations will refl ect the balance of effi cacy and
safety and will not deal in detail with the toxicity of DMARDs.
The most important pieces of information in this regard are
provided in separate publications on the SLRs,18–22 which
indeed are part and parcel of these recommendations, since
they provide their bases. Thus, the recommendations shown
here will primarily deal with agents whose toxicity appears
to be manageable, assuming that users are either aware of the
respective risks or will adhere to the information provided in
the package inserts. Also, where toxicity appears to be a major
concern, a general warning will be included in the respective
recommendation.
The expert committee comprised 25 rheumatologists, two
patients, one infectious disease specialist, one health economist
and fi ve fellows. The members of this task force came from 12
European countries and from the USA. The expert commit-
tee was divided into fi ve subgroups; each consisted of fi ve to
seven members including one fellow and dealt with one of the
above topics. At the fi rst meeting, these subgroups prioritised
the research questions, defi ned the appropriate search terms and
reported to the full committee, which took the fi nal decisions by
consensus.
Subsequently, the fellows, with the help of their mentors,
performed the respective SLR searching PubMed, Embase,
Medline and the Cochrane library and also recent abstracts, up
to the middle of 2009. The SLRs included meta-analyses, sys-
tematic reviews, randomised controlled trials (RCTs), non-RCTs
and observational studies, including data from registries. The
individual research questions, in particular on the effi cacy and
toxicity of the agents under investigation, were examined by
looking at the population of adult patients with RA, the type of
agent, the control used for comparison and the outcome. If pos-
sible, outcome was quantifi ed using effect sizes, which are unit-
less and therefore allow for the analysis of effi cacy irrespective of
the measures evaluated in individual clinical trials; these data will
be solely discussed in the reports on the SLRs. Categorisations
of evidence and strength of recommendation were determined
according to the standards of the Oxford Centre for Evidence
Based Medicine.23
At the second task force meeting, the fellows presented the
results of the SLR in an aggregated form to the subgroups. The
members of the subgroups debated and evaluated the evidence
presented and formulated preliminary sets of recommendations.
These proposals were reported to the entire task force, which
discussed the suggestions on the recommendations in detail,
amended them as deemed appropriate in the course of the con-
sensus fi nding and took the fi nal decisions. An ultimate round of
refi nement of the wording was done via electronic communica-
tion, by which also an anonymous voting on the level of agree-
ment was performed. In addition, respondents were asked to
indicate which of the statements were in line with their current
treatment practice and, if not, whether they would change that
practice. The task force started its work in December 2008 and
fi nalised it in June 2009.
RESULTS
Overarching principles
Before dealing with the actual treatment recommendations, the
task force discussed several principles that were deemed impor-
tant to be conveyed to those with RA or involved with the man-
agement of RA. These principles for the care of patients with RA
are of such generic nature that they were felt to be ‘overarching’
(table 1). The task force decided unanimously on these three
principles.
(A) Rheumatologists are the specialists who should primar-
ily care for patients with RA. This statement stems from
the evidence that patients with RA followed up by
rheumatologists, in comparison with other doctors,
are diagnosed earlier, receive DMARD treatment more
frequently and have better outcomes in all major char-
acteristics of RA, in particular joint damage and physical
function.24–28 Rheumatologists check the disease activity
of their patients with RA with appropriate instruments
and are well aware of the indications, contraindications
and adverse effects of DMARDs; this has become of
particular importance with the advent of modern treat-
ments and strategies. Therefore, patients with infl amma-
tory arthritis, in general, and suspected RA, in particular,
should be referred to rheumatologists as early as pos-
sible, since a delay in such a referral is one of the most
daunting causes of tardy institution of effective treat-
ment.9 29 However, the task force intentionally added the
term ‘primarily’ to this statement, since the management
of patients with RA should be shared with primary care
doctors and other health professionals in a multidisci-
plinary approach. Also, in countries lacking suffi cient
numbers of rheumatologists, this task may have to be
taken over by other doctors with experience in caring for
patients with RA.
(B) Treatment of patients with RA should aim at the best care and
must be based on a shared decision between the patient and the
rheumatologist. Two themes govern the contents of this
principle—fi rst, the term ‘best care’, which the task force
felt to be conveyed by the subsequent recommendations,
and second, the phrase ‘shared decision’ with the patient,
which refers to the need to discuss treatment aims,
management plans and reasons for the recommended
approaches with the patient.
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(C) RA is expensive in regards to medical costs and productiv-
ity costs, both of which should be considered by the treating
rheumatologist. The expert committee wished to encapsu-
late that the direct and indirect costs of RA, especially if
insuffi ciently treated, are very high.28 30–33 Modern treat-
ments, particularly biological agents, are expensive,30 34 35
but may enable lowering of short- and long-term indirect
costs of disease—an actuality that should be kept in
mind for individual treatment approaches as well as
reimbursement considerations. This underlying principle
also reinforces the decision to evaluate economic aspects
in relation to the individual recommendations to exam-
ine the cost effectiveness of RA treatment.
Recommendations
In each subgroup, the members discussed the evidence provided
by the fellows in their SLRs in detail and agreed on fi ve to eight
recommendations for the respective topic. These preliminary
statements on the management of RA with synthetic DMARDs,
GCs and biological agents, as well as on treatment strategies and
economic aspects, were subsequently reviewed intensively by
the whole task force, synthesised and voted upon. This process
led to 15 recommendations on drug management and treatment
strategies. Each of these 15 recommendations was then sub-
jected to an economic valuation in accordance with the results
obtained by the economics subgroup of the task force.
The 15 recommendations (detailed in table 1) are presented in
the text below in an abbreviated version. The levels of evidence
and strengths of recommendation for each recommendation are
then shown in table 2 and the economic valuation in table 3.
The 15 recommendations are ordered by a logical sequence or
procedural and chronological hierarchy rather than by any major
weight of importance, with the exception of the fi rst two points
which constitute the foundation of all subsequent items. They
also serve as basis for the algorithm provided in fi gure 1.
(1) Synthetic DMARDs early— The task force was unani-
mous in its view that in the vast majority of patients
with RA the fi rst treatment approach should include
synthetic DMARDs, since a signifi cant proportion of
patients can attain a state of very low disease activity or
remission36–39; the types of DMARD with evidence of
effi cacy will be discussed in items 3–6. Moreover, since
any delay in the start of DMARD treatment in patients
with RA may lead to a worse outcome in comparison
with an early start of treatment,8 10 40 DMARD treatment
should be started as soon as a diagnosis of RA has been
made. However, a diagnosis of RA in its earliest stage is
not always easy and a suspected diagnosis of RA may
be suffi cient to initiate DMARD treatment. Importantly,
American College of Rheumatology (ACR) and EULAR
have collaboratively developed new criteria that are
pertinent for this early phase of the disease.41
(2) Treatment targeting remission or low disease activity—
Undoubtedly, attaining a state of remission or low
disease activity leads to better structural and functional
outcomes than allowing residual disease activity11 42–46
and the earlier such a state is achieved the better.43 47
Thus, remission is the primary therapeutic aim, espe-
cially in early RA, though low disease activity may be
an appropriate alternative, especially in patients with
longstanding RA, as was also concluded by an expert
committee recently engaged in defi ning a treatment
target for RA.48 Strategic trials have shown that aiming at
Table 1 Recommendations for the management of rheumatoid arthritis
with non-biological and biological disease-modifying antirheumatic
drugs.
Overarching principles
A Rheumatologists are the specialists who should primarily
care for patients with RA
Treatment of patients with RA should aim at the best care
and must be based on a shared decision between the
patient and the rheumatologist
RA is expensive in regards to medical costs and productivity
costs, both of which should be considered by the treating
rheumatologist.
B
C
Final set of 15 recommendations for the management of RA
1Treatment with synthetic DMARDs should be started as
soon as the diagnosis of RA is made
2Treatment should be aimed at reaching a target of
remission or low disease activity as soon as possible in
every patient; as long as the target has not been reached,
treatment should be adjusted by frequent (every 1–3
months) and strict monitoring
3 MTX should be part of the fi rst treatment strategy in
patients with active RA
4 When MTX contraindications (or intolerance) are present,
the following DMARDs should be considered as part of the
(fi rst) treatment strategy: lefl unomide, SSZ or injectable
gold
5 In DMARD naïve patients, irrespective of the addition
of GCs, synthetic DMARD monotherapy rather than
combination therapy of synthetic DMARDs may be
applied
6 GCs added at low to moderately high doses to synthetic
DMARD monotherapy (or combinations of synthetic
DMARDs) provide benefit as initial short-term treatment,
but should be tapered as rapidly as clinically feasible
7If the treatment target is not achieved with the fi rst
DMARD strategy, addition of a biological DMARD should be
considered when poor prognostic factors are present; in the
absence of poor prognostic factors, switching to another
synthetic DMARD strategy should be considered
8 In patients responding insuffi ciently to MTX and/or
other synthetic DMARDs with or without GCs, biological
DMARDs should be started*; current practice would be to
start a TNF inhibitor (adalimumab, certolizumab, etanercept,
golimumab, infl iximab)† which should be combined with
MTX*
9 Patients with RA for whom a fi rst TNF inhibitor has failed,
should receive another TNF inhibitor, abatacept, rituximab
or tocilizumab
10In cases of refractory severe RA or contraindications to
biological agents or the previously mentioned synthetic
DMARDs, the following synthetic DMARDs might be also
considered, as monotherapy or in combination with some
of the above: azathioprine, ciclosporin A (or exceptionally,
cyclophosphamide)
11Intensive medication strategies should be considered
in every patient, although patients with poor prognostic
factors have more to gain
12 If a patient is in persistent remission, after having tapered
GCs, one can consider tapering biological DMARDs‡,
especially if this treatment is combined with a synthetic
DMARD
13In cases of sustained long-term remission, cautious titration
of synthetic DMARD dose could be considered, as a shared
decision between patient and doctor
14DMARD naïve patients with poor prognostic markers might
be considered for combination therapy of MTX plus a
biological agent
15When adjusting treatment, factors apart from disease activity,
such as progression of structural damage, comorbidities and
safety concerns should be taken into account
Symbols *, † and ‡ refer to levels of evidence provided in table 2.
DMARD, disease-modifying antirheumatic drug; GCs, glucocorticoids; MTX,
methotrexate; RA, rheumatoid arthritis; SSZ, sulfasalazine; TNF, tumour necrosis factor.
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low disease activity or remission by adjusting treatment
every 1–3 months in conjunction with strict monitor-
ing is associated with a better clinical, radiographic and
functional outcome than with an unstructured follow-
up.11 13 49 Thus, the treatment target should preferably
be reached, or almost reached, within 3 months and
defi nitely attained by a maximum of 6 months; while
this time frame was not directly tested in comparative
trials, this expert opinion is based on the use of a 1–3
months’ period for switching treatments in strategy
trials11–14 and on data showing that disease activity
states at 3–6 months after treatment initiation predict
outcome at later time points.50 Within this time frame of
3–6 months patients should be followed up meticulously
(every month if necessary) and existing treatment should
be intensifi ed or ultimately changed for another.48 In line
with these recommendations, monitoring should be reg-
ularly performed. While several different measures have
been employed in various strategy trials,21 expert opinion
has recently suggested using composite measures of dis-
ease activity which include joint counts.48 Valid measures
for this purpose have been recently reviewed and include
the Disease Activity Score (DAS), 28-joint count DAS
(DAS28), Simplifi ed Disease Activity Index and Clinical
Disease Activity Index.51
(3) MTX as initial choice—MTX is a highly effective drug for
disease modifi cation in RA,52 and more recent insights
suggest that MTX at higher weekly doses (20–30 mg)
is more effective than MTX at lower weekly doses
(7.5–15 mg).2 53 MTX is considered the anchor drug in
RA,54 both on the basis of its effi cacy as monotherapy
and on the basis of its ability to increase the effi cacy of
biological DMARDs when used in combination,55–59 as
well as the benefi cial long-term safety profi le.60 MTX is
effective in DMARD naïve patients with early RA,13 49
56 61 and its clinical effi cacy has neither been surpassed
by other synthetic DMARDs nor consistently by tumour
necrosis factor (TNF) inhibitor monotherapy.37 55 56 62 For
these reasons the task force considered that MTX should
be instituted at the earliest time point in patients with
RA. This statement comprises three items in addition
to the recommendation for using MTX: fi rst, it uses the
wording ‘part of the fi rst treatment strategy’, implying
that MTX may have to be combined with other agents
(see below); second, it refers to ‘active RA’, implying
that patients with low disease activity may not necessar-
ily need treatment with MTX; and third, the statement
indicates implicitly that a strategy using MTX should
be applied also to patients with active RA who have
previously not received MTX, but only other synthetic
DMARDs. Obviously this recommendation does not
pertain to patients for whom a contraindication for MTX
use is present (see below).
(4) Lefl unomide, SSZ or injectable gold—There is currently
insuffi cient evidence that lefl unomide, SSZ or intra-
muscular gold salts are inferior to MTX.37 38 62–64
Nevertheless, because of the wealth of effi cacy and
safety data available for MTX, the three mentioned
DMARDs should be used instead of MTX as fi rst
DMARD treatments mainly if there are contraindica-
tions to (or intolerance of) MTX. In analogy with the
previous paragraph, these MTX alternatives should also
be considered as a part of a treatment strategy. The
rather prominent place of parenteral gold salts has been
the subject of intensive debate, but can be justifi ed by
the currently available high-level evidence,63 65 66 and
this decision was ultimately backed by the majority
of the task force. In addition to the drugs mentioned
above, antimalarial drugs (hydroxychloroquine and
chloroquine) are also used in RA. They show some
effi cacy as monotherapy with respect to signs and
symptoms67 and are frequently used as part of combina-
tion therapies.42 68 69 It is, however, not clearly estab-
lished if antimalarial drugs confer additional effi cacy in
combination therapy. In addition, antimalarial drugs do
not inhibit structural damage suffi ciently, especially in
comparison with other agents such as SSZ.70 Therefore
they have not been mentioned more prominently in the
recommendation statement. Nevertheless, on the basis
of their clinical effi cacy as monotherapy they may have
some value in patients with very mild disease who have
contraindications to other compounds.
(5) Synthetic DMARD monotherapy or combination therapy—
Over the past two decades, combination therapy with
various synthetic DMARDs has been suggested to
convey superior effi cacy in comparison with monothera-
py.7 42 68 69 71 Results of clinical trials testing the addition
of synthetic DMARDs to MTX in patients with residual
disease activity despite MTX treatment have often been
used to support the assumption of an added benefi t72 73;
however, in these studies an appropriate control (switch)
arm was lacking and the proportion of responders receiv-
ing combination therapy did not exceed the proportion
of responders receiving the monotherapy components.74
An important fact to consider to truly appreciate the
content of this recommendation, however, is that in
most clinical trials comparing combination therapy with
monotherapy head to head, GCs were either manda-
tory in the combination therapy arm or GC use was
different between both arms, which probably explains
the superiority of combination therapy.74 Several other
trials suggest that in the absence of GCs neither a start
with combinations of synthetic DMARDs nor a step up
Table 2 Level of evidence, grade of recommendation and level of
agreement
Recommendation
1
2
3
4
5
6
7
8
Level of evidence
1a
1b
1a
1a
1a−
1a−
5
*1b
†4
1b
1a-
1b
3b
4
2b
3b
Grade of
recommendation
A
A
A
A
A
A
D
*A
†C
A
B
B
B
C
C
C
Level of agreement
9.9±0.4
9.7±0.7
9.8±0.5
8.6±1.5
8.5±2.0
8.7±1.7
8.8±1.7
9.3±1.5
9
10
11
12
13
14
15
9.5±0.9
8.1±1.6
9.2±1.2
8.4±1.6
8.5±1.9
8.0±2.3
9.5±1.1
Symbols refer to the corresponding symbols in the recommendations presented in
table 1 and show the respective evidence for those.
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combination therapy are better than monotherapies or
switching DMARDs for the major outcomes.49 75–77 The
SLR on this allowed a fi rm conclusion to be drawn.18
Furthermore, in DMARD naïve patients the balance of
effi cacy and toxicity favours MTX monotherapy versus
combination therapy, while the evidence is inconclusive
in DMARD inadequate responders.78 Therefore, the task
force decided to use the word ‘may’ here. It is impor-
tant to keep in mind that if combination therapy with
synthetic DMARDs does not allow the treatment target
to be achieved, it is impossible to disentangle which of
the agents was insuffi ciently effective, precluding better
usage of synthetic DMARDs. The statement contains yet
another element—namely, the segment “irrespective of
the addition of GCs”. The committee was unanimous in
its opinion that the addition of GCs to either monother-
apy or combination therapy with DMARDs improves
outcomes. However, studies allowing a direct compari-
son of GCs plus DMARD monotherapy versus GCs plus
combination DMARDs have not been done.
(6) Glucocorticoids—GCs have been shown to have not only
anti-infl ammatory but clearly also disease-modifying
properties.5 79 80 The evidence that DMARD monother-
apy is as effi cacious as DMARD combination therapy
suggests that the signifi cantly better outcomes of trials
using combinations of synthetic DMARDs plus GCs
versus DMARD monotherapy might be due to the GC
component.7 12 42 This notion fi nds important support
in studies which show that adding GCs to DMARD
monotherapy3 4 is benefi cial. GC treatment has been
added to DMARDs successfully at low doses (<10 mg/
day),3 4 42 but more rapid improvement may be achieved
by addition of GCs at higher doses for the short term.7
49 However, the added effi cacy of high-dose GCs has
not yet been compared with that of low-dose GCs
and, therefore, suffi cient evidence for this is lacking.
Importantly, long-term use of GCs can lead to adverse
events,81 but there may also be safety concerns in
the intermediate term, although most studies on the
toxicity of GCs are of low quality and short duration.
Nevertheless, their toxicity, particularly in the intermedi-
ate to long term, should in the opinion of the task force
not be disregarded and thus GCs should be used with
caution and preferably for only short periods of time.
Consequently, GCs should be tapered as rapidly as pos-
sible in accordance with the clinical situation. The safety
of GCs was also an important aspect of the EULAR rec-
ommendations on the management of GC treatment.82
(7) Addition of a biological DMARD or switch to another synthetic
DMARD—This statement introduces the importance of
prognostic markers in treatment decisions in RA. Factors
believed to predict bad outcome independently are (a)
the presence of autoantibodies, that is, rheumatoid factor
and/or anticitrullinated peptide antibodies, particularly
at high levels; (b) high disease activity as measured by
composite indices (DAS, DAS28, Simplifi ed Disease
Activity Index and Clinical Disease Activity Index),
swollen joint counts or acute phase reactants (C reac-
tive protein, erythrocyte sedimentation rate); (c) early
occurrence of erosions83–87; these factors have recently
also been amalgamated into a risk model.88 The task
force agreed that patients failing to reach the treatment
target on an initial strategy with synthetic DMARDs,
in whom poor prognostic markers as defi ned above are
absent, could be switched to another synthetic DMARD
strategy for 3–6 months before further decisions on the
institution of a biological agent are taken; these other
DMARDs have been mentioned in recommendation 4.
However, patients for whom an initial DMARD failed
and who have poor prognostic markers should have the
opportunity to receive a biological DMARD in addition
to their synthetic DMARD. Interestingly, closing a gap
of information by using a control arm receiving active
treatment, a recent study which was not part of the
SLR reported that for patients with early RA who had
failed to reach low disease activity after 3 months’ MTX
monotherapy, the addition of a TNF inhibitor yielded
signifi cantly better clinical outcomes than the addition of
SSZ plus hydroxychloroquine.89 These data also corrobo-
rate the conclusions discussed in recommendations 5 and
6—namely, that a combination of synthetic DMARDs
in the absence of added GCs (even triple treatment of
MTX, SSZ and hydroxychloroquine) has limited effi cacy
and may not have higher effi cacy than if the patients had
been switched to SSZ, as was shown in the BeSt trial.12
This limited (but partly exhibited) effi cacy of such a syn-
thetic DMARD regimen also supports the expert opinion
of switching patients for whom a fi rst DMARD strategy
has failed and who do not have bad prognostic markers
to another DMARD (or eventually DMARD combina-
tion). In contrast, for patients for whom initial MTX or
other synthetic DMARDs (ideally with GCs) has failed
and who have bad prognostic indicators a biological
DMARD, in general, and a TNF inhibitor, in particular,
should be employed. Importantly, however, no ran-
domised controlled or observational clinical trials to date
have tested this approach of differential treatment based
on prognostic factors. Therefore, this statement is at the
level of an expert opinion, but is supported by various
indirect evidence provided in the existing literature.
(8) Initiation of a TNF inhibitor—This expansion of statement
No 7, which applies to patients followed according to
that previous statement, emphasises that biological
agents are effective if synthetic DMARDs have failed
(level 1a, grade A) and that they should be combined
with MTX (or other DMARDs), since this combination
has greater effi cacy than monotherapy with most bio-
logical agents; this is well established for TNF inhibitors
on the basis of respective comparative phase III trials55
56 and for rituximab and tocilizumab on the basis of
comparative phase II trials58 59 (level 1b, grade A). At the
time of the SLR, the only biological agents licensed in
Europe for treating patients with RA with active disease
despite synthetic DMARD treatment were the TNF
inhibitors and tocilizumab; rituximab and abatacept
are currently licensed only for use after failure of TNF
inhibitors. In the USA, though not currently in Europe,
abatacept can also be used in these former patients; in
light of more recent clinical trial data,90 91 abatacept and
rituximab may receive similar approval as fi rst biologi-
cal agents by the European regulatory authorities in due
course. It is noteworthy that some TNF inhibitors such
as adalimumab and etanercept are licensed as mono-
therapy on the basis of their effi cacy in clinical trials,
but the data on their clinical superiority compared with
MTX monotherapy are partly mixed.55 56 92 Recent data
suggest that monotherapy with tocilizumab is more
effective than monotherapy with DMARDs such as
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MTX93 94; however, this RCT did not include a third arm
using the combination of both so that it is not clear to
date whether in patients with early RA monotherapy
with tocilizumab is similarly or less effective than com-
bination therapy with tocilizumab and MTX. Currently,
the largest array of safety information is available for
the TNF inhibitors owing to their use for more than one
decade and the availability of large long-term registries.
These compounds comprise adalimumab, etanercept
and infl iximab, but certolizumab and golimumab have
meanwhile also been approved. However, it should
be borne in mind that this represents current expert
opinion and may change over time, specifi cally with the
recent approval of other biological agents as potential
fi rst biological agent for DMARD inadequate respond-
ers—namely, tocilizumab in Europe and abatacept in
the USA and other non-European countries. It should
also be mentioned here that anakinra, the IL-1 receptor
antagonist, while effective in individual patients with
RA, did not show a high level of clinical effi cacy in clini-
cal trials95 96 and therefore has not been recommended
as a major biological agent for use in RA.
(9) Abatacept, rituximab or tocilizumab—There is high-level
evidence from one RCT each that abatacept, golimumab,
rituximab and tocilizumab are effective in patients for
whom TNF inhibitor therapy has failed97–100 (level 1b,
grade A). These data are partly supported by observa-
tional studies stemming from registries which suggest
that switching from one TNF inhibitor to another, as
well as switching from TNF-blocking agents to ritux-
imab, is benefi cial.101–103 To date, the committee could
not identify RCTs in which switching was appropriately
compared between different biological agents and there-
fore a preference for a particular biological agent in this
situation could not be established.104
(10) Azathioprine, ciclosporin A or cyclophosphamide—RA can
run a course that is refractory to several DMARDs and
biological agents and can be severely destructive and
disabling.99 100 105 106 While in the previous recommenda-
tions four synthetic DMARDs and nine biological agents
have been mentioned, allowing a variety of therapeutic
options, refractoriness may and still will occur. In order
to meet the needs of this group of patients, the task force
has referred to agents for which the literature provides
evidence on effi cacy. However, one needs to bear the
toxicity in mind, especially in the case of ciclosporin A
and cyclophosphamide; the latter drug should only be
used in exceptional situations. A number of presumed
DMARDs were excluded here, because the evidence
for their effi cacy was deemed insuffi cient; these include
D-penicillamine, minocycline, auranofi n, tacrolimus and
chlorambucil. With respect to antimalarial drugs we refer
to the paragraph on recommendation 4.
(11) Intensive medication strategies—This statement supple-
ments several of the previous recommendations on drug
treatment. Advocating intensive medication strategies
refers to content of the strategy, such as MTX plus GCs
or MTX plus biological agents, as well as tight monitor-
ing and rapid switching of treatments if treatment goals
are not attained (benchmarking).12 107 The statement
that patients with poor prognostic factors have more
to gain fi nds its basis in the appreciation that patients
with a favourable prognosis very often respond similarly
to low-intensity monotherapy or intensive medication
strategies,87 88 but that patients with a severe and aggres-
sive disease course often do not respond suffi ciently
well to DMARD monotherapy or combination therapy
without addition of GCs or biological agents.
(12) Tapering biological DMARDs—It is currently unclear how
to continue or discontinue treatment in patients who
have achieved remission. A thoroughly performed RCT
on stopping synthetic DMARDs in patients in remission
has shown that only about one-third of the patients who
maintained their DMARDs fl ared as opposed to about
two-thirds of those who stopped them108; moreover,
remission was much harder to re-achieve after stopping
DMARDs.109 This was also concluded in a recent meta-
analysis devoted to this issue.110 The fi rst aspect embed-
ded in this statement relates to the duration of remission:
it should be persistent—that is, having lasted for several
months, before tapering of synthetic and/or biologi-
cal DMARDs should be considered. However, before
tapering DMARDs, GCs must have been tapered in line
with statement No 6 and remission have persisted. The
task force felt (by expert opinion) that biological agents
could then be slowly tapered by expanding the interval
between doses or reducing the dose, while synthetic
DMARDs should be continued. No particular time frame
was given here, since there are no data available; from an
expert opinion’s view remission for at least 12 months
might be regarded as ‘persistent’.110
(13) Tapering of synthetic DMARDs—This statement follows
the preceding one, suggesting that tapering synthetic
DMARD treatment in cases of longstanding remission
could be considered after GCs and biological agents
have been discontinued. Evidence supporting such an
approach does not exist—neither details of a time frame
nor dosing or interval duration during the tapering pro-
cess. Thus, the means of tapering is left to the discretion
of patient and doctor. However, in light of the available
data showing that stopping DMARDs is associated with
an increased fl are frequency,108 110 the committee felt that
tapering should be performed cautiously and assessed
rigorously.
(14) Biological treatment in DMARD naïve patients While
biological DMARDs, in line with statements Nos 7 and
8, should, in general, be applied to patients for whom
synthetic DMARD(s) have failed, the committee strongly
felt that there are some patients for whom fi rst-line
biological treatment combined with MTX has to be
considered. Such patients will usually have unfavour-
able prognostic signs, including very active disease or
early structural damage. Currently, only TNF inhibi-
tors are licensed for such patients, but other biological
agents may receive similar approval with more trial data
in the future. When evaluating results of trials using
TNF inhibitors plus MTX in MTX naïve individuals
and studies of the same compounds in patients with
active disease despite MTX treatment,1 55 56 61 111–113
patients naïve to MTX had higher response rates than
MTX insuffi cient responders, but many of the MTX-
naïve patients in the combination therapy arms would
have responded to MTX monotherapy anyway. Thus,
while, there is also additional evidence from strategic
trials that employing TNF inhibitors plus MTX early
is an effective treatment,36 49 more recent data suggest
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that this approach may not be more effective in patients
with early RA than starting synthetic DMARDs fi rst
and adding a biological agent to the DMARD rapidly (in
that study after 3 months) if active disease prevails.114
However, hitherto no clinical trial has examined the
actual expert-based recommendations to use such a
strategy in few, selected patients as described above.
Indeed, this statement received the lowest level of agree-
ment (8.0/10) and it was the only item for which a large
number of rheumatologists stated that it was not their
current practice and that this recommendation would
change their practice.
(15) Adjustment of treatment—Prudence and knowledge will
guide one to bear toxicity of agents and comorbidities
in mind when prescribing drugs for RA. However, the
rapidity of progression of joint damage, in addition to
disease activity and other prognostic factors, may sup-
port decision-making in relation to statements Nos 7
and 14, especially if joint damage appears to progress
considerably despite the achievement of the desired
treatment target; however, lag periods47 have to be taken
into consideration before making such decision.
Economic aspects
The cost effectiveness of the therapeutic measures recom-
mended above has been assessed in detail by a dedicated
SLR, which is also published separately.22 In sum, the avail-
able data suggest that all recommendations are known to be
Figure 1 Algorithm based on the European League Against Rheumatism recommendations on rheumatoid arthritis management. DMARD, disease-
modifying antirheumatic drug; MTX, methotrexate; RF/ACPA, rheumatoid factor/anti-citrullinated peptide antibodies; TNF, tumour necrosis factor. *The
treatment target is clinical remission or, if remission is unlikely to be achievable, at least low disease activity.
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cost effective with the exception of statement No 14 (table 3).
However, an economic analysis considering only the excep-
tional patients considered in recommendation No 14 has not
been performed. The committee does not preclude the possi-
bility that in this particular category of patients, the approach
of starting biological agents as fi rst-line DMARD treatment
may be cost effective.
Research agenda
Research questions have been formulated in all subgroups.
These questions were assessed by the task force and the result
of this discussion is summarised in table 4.
DISCUSSION
The task force has formulated 15 brief statements on the man-
agement of RA with synthetic and biological DMARDs. These
statements were mostly based on a SLR with consensus fi nding
on the wording of the recommendations, but partly also solely
based on expert opinion. By this process and by stating the
respective level of evidence and strength of recommendation for
each item, the committee adhered to the EULAR standardised
operating procedures for the development of recommenda-
tions.17 Moreover, where evidence was lacking and the task
force had to arrive at an expert opinion, a research agenda was
formulated to expedite the generation of evidence in the future.
The reasoning behind each statement and, particularly,
behind the recommendations’ specifi c wordings is explained
in detail in the results section and will not be repeated here.
Importantly, the overall agreement with these statements,
assessed anonymously several weeks after their formulation,
was very high with means of ≥8/10 for all and >9/10 for seven
of the 15 items (statements Nos 1–3, 8, 9, 11 and 15). The low-
est agreement (8/10) was received by the recommendation to
start biological agents plus MTX as fi rst DMARD strategy in
selected patients with very high disease activity and poor prog-
nostic markers (No 14). Indeed, it was also the only item where
many rheumatologists stated that it was not their current prac-
tice and that this recommendation would change their current
treatment practice (data not shown).
Dividing the task into fi ve specifi c areas may have helped
unambiguous conclusions to be reached. Three of these areas
were related to actual pharmacological treatment. Moreover,
separating the SLRs on synthetic DMARDs into those with and
those without addition of GCs facilitated the derivation of rec-
ommendations on combination therapy with a clarity that had
previously been unappreciated; at the same time, this clarity
raised new questions which require further elucidation.
It is worth noting that the task force felt that the best evi-
dence for effi cacy was available for four synthetic DMARDs
(MTX, lefl unomide, SSZ and parenteral gold; statements Nos 3
and 4) and eight biological agents (adalimumab, certolizumab,
etanercept, golimumab, infl iximab, abatacept, rituximab and
tocilizumab; statements Nos 7–9). These 12 agents are also
clearly stated in the itemised recommendation sentences. Two
additional agents are mentioned in the text only—namely, anti-
malarial drugs and anakinra, because while effective in RA, their
effi cacy is lower than that of other agents in their general class,
synthetic or biological. A fi nal group of DMARDs is referred
to as a last resort for patients for whom the above drugs have
failed (statement No 10). It should be mentioned here that GCs
also have disease-modifying ability,80 but the task force does
not suggest using them as monotherapy owing to their adverse
event profi le.81 Also, the readers are referred to the accompany-
ing papers on the SLRs for full information on the effi cacy of the
respective agents.
The task force was convinced that modern treatment of RA
should be goal oriented and governed by a strategic treatment
approach. Remission or at the least low disease activity should
be the therapeutic goal, in line with a recent recommendation on
treatment goals in RA.48 115 On the way to attaining this target,
patients should be closely monitored using composite disease
Table 4 Research agenda

1
Research agenda
What is the effi cacy of GCs when added to DMARDs other than MTX
or combinations of synthetic DMARDs with MTX, such as GC plus
SSZ, compared with GC plus MTX and biological agents+MTX?
How comparable or different is the effi cacy of the various biological
agents in patients with active disease despite MTX?
How comparable or different is the effi cacy of the various biological
agents in patients who did not respond or lost response to TNF
inhibitors?
Can biological agents be stopped in sustained remission with
maintenance of remission, and how does stopping biological agents
compare with stopping GC plus MTX or stopping GC?
What is the best way to taper treatment with synthetic and
biological DMARDs in patients with longstanding remission?
(comparison of different tapering ways)
Which differences will exist when comparing treatment strategies
starting in parallel with MTX monotherapy plus GC, combination of
synthetic DMARDs including MTX plus GC, combination of synthetic
DMARDs including MTX without GC and biological agents plus MTX?
How big is the difference of clinical, functional, radiographic effi cacy
when a treatment strategy aiming at remission by newly defi ned
ACR/EULAR remission criteria is compared with a strategy aiming at
achievement of low disease activity?
Can we fi nd predictors of response to synthetic DMARDs and
different biological agents?
What is the effect of adding antimalarial drugs to MTX or to
MTX+SSZ?
How cost effective is treating individuals with exceptionally high risk of
rapid progression with biological agents versus synthetic DMARDs plus
GCs when compared with using a sequence of agents as mandated by
social security agencies or NICE?
2
3
4
5
6
7
8
9
10
This research agenda is partly based on recommendations derived by expert opinion for
which suffi cient evidence is lacking.
ACR/EULAR, American College of Rheumatology/European League Against
Rheumatism; DMARD, disease-modifying antirheumatic drug; GCs, glucocorticoids;
MTX, methotrexate; NICE, National Institute of Health and Clinical Excellence; SSZ,
sulfasalazine; TNF, tumour necrosis factor.
Table 3 Economic valuation of recommendations
Recommendation
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Level of evidence and strength of
recommendation for cost effectiveness
NA
2c, B
2b, B
1b, 2b; B
2c, B
2c, B; 5, D
2b, B
2b, B
2b, B
NA
NA
2c, B
2c, B
1b, A (for being not cost effective*)
NA
*Not cost effective on the group level assessed in the respective studies, but not
necessarily on the level of the exceptional individual patient as suggested in the
recommendation.
NA, not applicable.
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activity measures116 117 and treatment adapted in accordance
with the current recommendation if the treatment aim is not
reached within preferably 3, but at most, 6 months.
The task force also felt strongly that, in general, DMARD
treatment should be started with MTX at appropriately high
doses, possibly with the addition of GCs for the short term,
before other measures are taken if the therapeutic goal is not
reached within a maximum of 6 months. The type of other
measures should depend on prognostic factors: while biological
agents may be considered in all patients after lack of achieve-
ment of remission or low disease activity on the above treat-
ment, such treatment is of more importance in the presence of
poor prognostic factors, like the presence of autoantibodies, a
high disease activity state or early erosive disease; it was felt
quite appropriate to consider alternative synthetic DMARDs
in the absence of poor prognostic factors. However, the task
force also voiced its opinion that occasional patients with a par-
ticular need for rapid, highly effective intervention, may benefi t
from starting a biological agent plus MTX as a viable and useful
option.
Particular emphasis emerged upon analyses of combination
therapies with synthetic DMARDs. The SLR did not reveal
general superiority of such combinations in comparison with
respective monotherapies. Only in studies where GCs were
added to synthetic DMARD(s) (or were given in higher doses or
more frequently than in controls) was there compelling evidence
for superiority of such combinations, but notably, the superior-
ity was present regardless of whether GCs were added to syn-
thetic DMARD monotherapy (such as MTX) or to combinations
of synthetic DMARDs (such as triple treatment with MTX, SSZ
and antimalarial drugs).
GCs have a special place in the discussion (statements Nos 5,
6, 8 and12). On the one hand, with respect to all outcomes, their
effi cacy as monotherapy, but especially in combination with
synthetic DMARDs is indisputable. On the other hand, their
toxicity, particularly in the intermediate to long term, was con-
sidered to be signifi cant,82 so they should be used with caution
and for only short periods of time. Tapering of GCs, but also
of biological agents and eventually synthetic DMARDs, was an
area of discussion too (statement No 13), but there is currently
insuffi cient evidence available about outcomes and potential
risks and hence how to proceed in this regards. Therefore, the
committee felt that tapering should only occur in cases of sus-
tained remission and should be part of the research agenda.
Figure 1 summarises the recommendations and the resulting
algorithm. Phase I comprises the initiation of DMARD treat-
ment once RA has been diagnosed (statements Nos 1–6). Phase
II deals with patients who did not achieve the treatment target
with strategy I (statements Nos 7 and 8); here, patients are strati-
fi ed according to prognostic factors and this strategy contains
the all steps until the use of the fi rst biological agent. Phase III
relates to patients for whom the fi rst biological compound failed
(statement No 9).
The recommendations on the management of RA provided
here by the EULAR Task Force are not the fi rst of their kind.
Indeed, EULAR has already published recommendations for
early RA,115 but the present document relates to all patients with
RA, rather than only those with early RA or undifferentiated
arthritis and provides far more detail about pharmacological
compounds. However, in line with the guidance document by
Combe et al, the fi rst bullet point calls for a DMARD to be initi-
ated as soon as RA is diagnosed.
Aside from the EULAR document on early RA management,
the ACR has provided therapeutic recommendations for several
years.118 However, its most recent 2008 recommendations are
complex and may not fully cover several aspects of drug treat-
ments and therapeutic strategies and goals.119 A comprehensive
document published by the National Institute of Health and
Clinical Excellence (NICE) of the UK29 at a time when our inves-
tigations were well advanced arrived at many conclusions that
are supported by ours and vice versa, although the NICE pub-
lication does not consider biological treatments. Finally, many
national rheumatological societies, such as the French or German
societies, have published national guidance documents.
These EULAR recommendations have been developed by
task force members from 12 European countries and the USA.
They are meant to serve rheumatologists in Europe and else-
where, although we are aware that not all agents mentioned
here are approved everywhere and, indeed, some agents had not
yet been approved in Europe when we dealt with the respective
literature, in the expectation that they would be licensed by the
time this manuscript was submitted for publication.
Beyond rheumatologists, the document is also provided
for patients with RA to inform them about current treatment
goals, strategies and opportunities, as recognised through the
important participation of patients in the task force. Finally,
this document is also meant for offi cials in governments, social
security agencies and reimbursement agencies, since it provides
the current state of thought in the area of RA management and
is based on as much evidence as was available. In this regard,
the economic valuation is also of signifi cance; indeed, all rec-
ommendations are supported by cost-effectiveness data, with
the exception of starting biological agents before synthetic
DMARDs; indeed, this conclusion is further supported by a
recent Cochrane meta-analyis which stated that in patients
with early RA. biological agents plus MTX may not differ sig-
nifi cantly from placebo plus MTX with risk ratios of 1.43 and
95% confi dence intervals of 0.98 to 2.09.120 However, in this
regard more research is needed, since the recommendation only
pertains to limited exceptional patients whose treatment has
not yet been studied economically. Indeed, several of the rec-
ommendations are more strongly based on expert opinion and
on clinical practice that has emerged in certain institutions than
on available evidence. It is here where the opportunity to gar-
ner evidence has to meet or disprove expert opinion or practice
and this is in part, the driver for the research agenda. Also, as
has been the case over the past decade, new data on existing or
new drugs or therapeutic strategies will emerge over the next
few years. Therefore, we will carefully watch developments
in the fi eld and assume that an amendment of these recom-
mendations may be needed in 2 years. Finally, irrespective of
availability or affordability of certain agents, these recommen-
dations can also serve as a template for national societies which
can adapt them to national clinical practices while remaining
within their general framework.
Authors affi liations 1Division of Rheumatology, Department of Medicine 3, Medical
University of Vienna, Vienna, Austria
22nd Department of Medicine, Hietzing Hospital, Vienna, Austria
3Department of Internal Medicine/Rheumatology, University Hospital Maastricht,
Maastricht, The Netherlands
4Department of Rheumatology, Leiden University Medical Centre, Leiden, The
Netherlands
5Rheumatology B Department, Paris Descartes University, Cochin Hospital, Paris,
France
6Section of Musculoskeletal Disease, Leeds Institute of Molecular Medicine, University
of Leeds, Leeds, UK
7Pierre et Marie Curie University-Paris VI, APHP, Rheumatology, Pitié-Salpétrière
Hospital, Paris, France
8Department of Rheumatology and Clinical Immunology, University Medical Center
Utrecht, Utrecht, The Netherlands
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9Department of Rheumatology and Clinical Immunology, Humboldt University, Charité
Hospital, Berlin, Germany
10Service d’Immuno-Rhumatologie, Montpellier University, Lapeyronie Hospital,
Montpellier, France
11Academic Clinical Unit of Rheumatology, Department of Internal Medicine, University
of Genova, Genova, Italy
12Division of Rheumatology, University Hospitals, Geneva, Switzerland
13Santiago University Clinical Hospital, Santiago University School of Medicine, Santiago
de Compostela, Spain
14EULAR Standing Committee of People with Arthritis/Rheumatism in Europe, Zurich,
Switzerland
15Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
16La Paz Hospital, Madrid, Spain
17University of Glasgow, Glasgow, UK
18Institute of Rheumatology and Clinic of Rheumatology, Charles University, Prague,
Czech Republic
19Department of Rheumatology, Radboud University Nijmegen Medical Centre,
Nijmegen, The Netherlands
20King’s College School of Medicine, Weston Education Centre, London, UK
21Department of Rheumatology, Jyväskylä Central Hospital, Jyväskylä, Finland
22Rheumatology Unit, Department of Clinical Medicine and Medical Therapy, Sapienza
Università di Roma, Rome, Italy
23Rheumatology Unit, Department of Medicine, Karolinska Institutet, Karolinska
University Hospital, Solna, Sweden
24Oregon Health and Science University, Portland, Oregon, USA
25Division of Clinical Decision Making, Informatics and Telemedicine, Tufts University
School of Medicine, Boston, Massachusetts, USA
26German Rheumatism Research Centre and Charité University Medicine, Berlin, Germany
Funding EULAR.
Competing interests The following authors declare that they have no potential
confl ict of interest: CG-V, SG, RK, MK, JN, MS, JW. The following authors declare a
potential confl ict of interest having received grant support and/or honoraria for consul-
tations and/or for presentations as indicated; JSS: Abbott, Amgen, BMS, Centocor,
Pfi zer, Roche, Schering-Plough,UCB, Sanofi -Aventis, Wyeth; RL: Abbott, Amgen, BMS,
Centocor, Merck, Pfi zer, Schering-Plough, UCB, Wyeth; FCB: Abbott, Schering-Plough,
Wyeth; MD: Pfi zer, Wyeth, Abbott, Roche, Novartis, Nordic Pharma, BMS, UCB; PE:
Abbot, BMS, Centocor, Pfi zer, Roche, Schering-Plough,UCB, Sanofi -Aventis, Wyeth;
MS: Abbott; DA: Abbott, Roche, Schering-Plough, BMS, UCB, Sanofi -Aventis; MB:
Roche, Abbott, BMS, Wyeth; LG: Abbott, Schering-Plough, Roche, UCB, BMS, Wyeth;
TH: Schering Plough, BMS, Biotest, Wyeth, Novartis, Roche, Sanofi -Aventis, Abbott,
Axis-Shield; JWJWB: Abbott, Roche, Wyeth, Schering Plough, Merck, Pfi zer, UCB,
BMS; GB: Abbott, Wyeth, Schering-Plough, Roche and UCB; BC: Abbott,BMS, Roche,
Schering, UCB,Wyeth; MC: Sanofi -Aventis, BMS, Pfi zer, Abbott; CG: Roche, BMS,
Abbott, Essex, Wyeth, UCB; JG-R: Abbott, BMS, Pfi zer, Roche, Schering-Plough,Wyeth
and UCB; TKK: Abbott, BMS, Roche, Schering-Plough,Wyeth, Pfi zer, MSD and UCB;
EMM: Wyeth/Pfi zer, Roche, Abbott Schering Plough/MSD; IM: Schering Plough, Pfi zer,
Roche and BMS; KP: Roche, Abbott, BMS, Pfi zer, MSD; PvR: Abbott, BMS, Roche,
Sanofi -Aventis, Schering-Plough, UCB, Wyeth; DLS: MSD, Pfi zer, Novartis, Roche,
Wyeth, Novartis, Schering Plough; TS: Abbott, Pfi zer, Sanofi -Aventis, Roche, UCB; GV:
Abbott, BMS, Roche, Sanofi -Aventis, Schering-Plugh, UCB, Wyeth; RvV: Abbott, Pfi zer/
Wyeth, Roche, Schering-Plough, BMS, UCB; KLW: Amgen, Wyeth, UCB, Genentech;
AZ: Abbott, Amgen, BMS, Essex/Schering-Plough, Merck, Pfi zer, Roche, Sanofi , UCB,
Wyeth; DvdH: Abbott, Amgen, BMS, Centocor, Chugai, Merck, Pfi zer, Roche, Schering-
Plough,UCB, Wyeth. Francis Berenbaum was the Handling Editor.
Provenance and peer review Not commissioned; externally peer reviewed.
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