EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update

Josef S. Smolen, Robert B.M. Landewé, Sytske Anne Bergstra, Andreas Kerschbaumer, Alexandre Sepriano, Daniel Aletaha, Roberto Caporali, Christopher John Edwards, Kimme L. Hyrich, Janet E. Pope, Savia De Souza, Tanja A. Stamm, Tsutomu Takeuchi, Patrick Verschueren, Kevin L. Winthrop, Alejandro Balsa, Joan M. Bathon, Maya H. Buch, Gerd R. Burmester, Frank ButtgereitMario Humberto Cardiel, Katerina Chatzidionysiou, Catalin Codreanu, Maurizio Cutolo, Alfons A. Den Broeder, Khadija El Aoufy, Axel Finckh, João Eurico Fonseca, Jacques Eric Gottenberg, Espen A. Haavardsholm, Annamaria Iagnocco, Kim Lauper, Zhanguo Li, Iain B. McInnes, Eduardo F. Mysler, Peter Nash, Gyula Poor, Gorica G. Ristic, Felice Rivellese, Andrea Rubbert-Roth, Hendrik Schulze-Koops, Nikolay Stoilov, Anja Strangfeld, Annette Van Der Helm-Van Mil, Elsa Van Duuren, Theodora P.M. Vliet Vlieland, René Westhovens, Désirée Van Der Heijde

Research output: Contribution to journalArticlepeer-review

11 Scopus citations


Objectives To provide an update of the EULAR rheumatoid arthritis (RA) management recommendations addressing the most recent developments in the field. Methods An international task force was formed and solicited three systematic literature research activities on safety and efficacy of disease-modifying antirheumatic drugs (DMARDs) and glucocorticoids (GCs). The new evidence was discussed in light of the last update from 2019. A predefined voting process was applied to each overarching principle and recommendation. Levels of evidence and strengths of recommendation were assigned to and participants finally voted on the level of agreement with each item. Results The task force agreed on 5 overarching principles and 11 recommendations concerning use of conventional synthetic (cs) DMARDs (methotrexate (MTX), leflunomide, sulfasalazine); GCs; biological (b) DMARDs (tumour necrosis factor inhibitors (adalimumab, certolizumab pegol, etanercept, golimumab, infliximab including biosimilars), abatacept, rituximab, tocilizumab, sarilumab and targeted synthetic (ts) DMARDs, namely the Janus kinase inhibitors tofacitinib, baricitinib, filgotinib, upadacitinib. Guidance on monotherapy, combination therapy, treatment strategies (treat-to-target) and tapering in sustained clinical remission is provided. Safety aspects, including risk of major cardiovascular events (MACEs) and malignancies, costs and sequencing of b/tsDMARDs were all considered. Initially, MTX plus GCs is recommended and on insufficient response to this therapy within 3-6 months, treatment should be based on stratification according to risk factors; With poor prognostic factors (presence of autoantibodies, high disease activity, early erosions or failure of two csDMARDs), any bDMARD should be added to the csDMARD; after careful consideration of risks of MACEs, malignancies and/or thromboembolic events tsDMARDs may also be considered in this phase. If the first bDMARD (or tsDMARD) fails, any other bDMARD (from another or the same class) or tsDMARD (considering risks) is recommended. With sustained remission, DMARDs may be tapered but should not be stopped. Levels of evidence and levels of agreement were high for most recommendations. Conclusions These updated EULAR recommendations provide consensus on RA management including safety, effectiveness and cost.

Original languageEnglish (US)
Pages (from-to)3-18
Number of pages16
JournalAnnals of the rheumatic diseases
Issue number1
StatePublished - Nov 10 2022


  • Antirheumatic Agents
  • Arthritis, Rheumatoid
  • Biological Therapy

ASJC Scopus subject areas

  • Rheumatology
  • Immunology and Allergy
  • Immunology
  • Biochemistry, Genetics and Molecular Biology(all)


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