The most recent American College of Rheumatology guidelines for the management of RA were published in 2016, and they are in need of an update, which is expected in the fall of 2020. The recent European League Against Rheumatism guidelines are more in line with current practice. MTX remains the cornerstone of therapy for most patients with RA; however, we are seeing more biologic monotherapy. Additionally, I think that people are beginning to liberalize their choices when their response to MTX has been inadequate to include non-TNF alternatives and the new oral targeted synthetic agents. Sullivan et al recently reported that TNFi cycling was seen in more than half of patients after a TNFi failure, but those data were collected between Q2 and Q3 2016 and much has changed since then. So, we are still generally MTX-centric, but an increasing number of patients are on either a biologic or a targeted synthetic DMARD. Approximately one-third of individuals with RA are not on MTX for a variety of reasons, including intolerance and contraindication, and we see no less of that.

Treatment considerations include efficacy, safety profiles, the individual patient’s systemic manifestations, and patient preferences. So, for example, there is some thought that patients with diverticulitis are not good candidates for interleukin-6 or Janus kinase inhibitors. Likewise, TNFi agents might be avoided in patients who are frail or have had a serious infection and are on prednisone. For those with anemia and fatigue, an interleukin-6 inhibitor may make sense. Or, when safety issues are a concern (eg, risk of hospitalized infection), one may gravitate toward abatacept. Our thinking on these distinct treatments is evolving based on the available data, but we do not yet have rich biomarkers to steer us toward one therapy or the other. There is also an increasing interest in oral options, which now include not only tofacitinib but also upadacitinib and baricitinib, with additional oral agents likely to be approved by the US Food and Drug Administration in the next few months. So, this is a big change in the prescribing landscape.