In DMARD-naïve patients, irrespective of the addition of glucocorticoids, conventional DMARD monotherapy or combination therapy of conventional DMARDs should be used
Rheumatologists should administer methotrexate (MTX) or combination therapy of MTX with other conventional synthetic DMARDs.
Among the DMARDs, MTX is considered the anchor drug and unless contraindicated, should be part of the first treatment strategy in patients at risk of persistent disease (2)
Azathioprine, cyclophosphamide and ciclosporin also have disease-modifying activity. However, they are usually reserved for people unresponsive to other DMARDs, due to the risk of serious adverse effects
There is some evidence showing the effectiveness of minocycline in RA. However, minocycline is not licensed for treating RA in the UK, and it is not used routinely
Leflunomide is a newer DMARD, which seems to be as effective as methotrexate or sulfasalazine at improving inflammation and function. However, its long-term effects are unclear
NICE guidelines on introducing and withdrawing DMARDs (3):
In patients responding insufficiently to MTX and/or other conventional DMARD strategies, with or without glucocorticoids, biological DMARDs (TNF inhibitors, abatacept or tocilizumab, and, under certain circumstances, rituximab) should be commenced with MTX (1)
Note:
Reference:
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