DMARD regimens

Introducing and withdrawing DMARDs (1)

• if newly diagnosed active rheumatoid arthirtis (RA)
  • offer a combination of DMARDs (including methotrexate and at least one other DMARD, plus short-term glucocorticoids) as first-line treatment as soon as possible, ideally within 3 months of the onset of persistent symptoms
• consider offering short-term treatment with glucocorticoids (oral, intramuscular or intra-articular) to rapidly improve symptoms in people with newly diagnosed RA if they are not already receiving glucocorticoids as part of DMARD combination therapy
• if recent-onset RA receiving combination DMARD therapy and in whom sustained and satisfactory levels of disease control have been achieved
  • cautiously try to reduce drug doses to levels that still maintain disease control
• if newly diagnosed RA for whom combination DMARD therapy is not appropriate
  • start DMARD monotherapy, placing greater emphasis on fast escalation to a clinically effective dose rather than on the choice of DMARD
• in people with established RA whose disease is stable, cautiously reduce dosages of disease-modifying or biological drugs. Return promptly to disease-controlling dosages at the first sign of a flare
• when introducing new drugs to improve disease control into the treatment regimen of a person with established RA, consider decreasing or stopping their pre-existing rheumatological drugs once the disease is controlled
• in any person with established rheumatoid arthritis in whom disease-modifying or biological drug doses are being decreased or stopped, arrangements should be in place for prompt review

Reference:

• 1. NICE (February 2009). Rheumatoid arthritis- The management of rheumatoid arthritis in adults