EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2019 update

Josef S. Smolen, Robert B.M. Landewé, Johannes W.J. Bijlsma, Gerd R. Burmester, Maxime Dougados, Andreas Kerschbaumer, Iain B. McInnes, Alexandre Sepriano, Ronald F. Van Vollenhoven, Maarten De Wit, Daniel Aletaha, Martin Aringer, John Askling, Alejandro Balsa, Maarten Boers, Alfons A. Den Broeder, Maya H. Buch, Frank Buttgereit, Roberto Caporali, Mario Humberto CardielDiederik De Cock, Catalin Codreanu, Maurizio Cutolo, Christopher John Edwards, Yvonne Van Eijk-Hustings, Paul Emery, Axel Finckh, Laure Gossec, Jacques Eric Gottenberg, Merete Lund Hetland, Tom W.J. Huizinga, Marios Koloumas, Zhanguo Li, Xavier Mariette, Ulf Müller-Ladner, Eduardo F. Mysler, Jose A.P. Da Silva, Gyula Poór, Janet E. Pope, Andrea Rubbert-Roth, Adeline Ruyssen-Witrand, Kenneth G. Saag, Anja Strangfeld, Tsutomu Takeuchi, Marieke Voshaar, René Westhovens, Désirée Van Der Heijde

Research output: Contribution to journalArticlepeer-review

1815 Citations (Scopus)


Objectives To provide an update of the European League Against Rheumatism (EULAR) rheumatoid arthritis (RA) management recommendations to account for the most recent developments in the field. Methods An international task force considered new evidence supporting or contradicting previous recommendations and novel therapies and strategic insights based on two systematic literature searches on efficacy and safety of disease-modifying antirheumatic drugs (DMARDs) since the last update (2016) until 2019. A predefined voting process was applied, current levels of evidence and strengths of recommendation were assigned and participants ultimately voted independently on their level of agreement with each of the items. Results The task force agreed on 5 overarching principles and 12 recommendations concerning use of conventional synthetic (cs) DMARDs (methotrexate (MTX), leflunomide, sulfasalazine); glucocorticoids (GCs); biological (b) DMARDs (tumour necrosis factor inhibitors (adalimumab, certolizumab pegol, etanercept, golimumab, infliximab), abatacept, rituximab, tocilizumab, sarilumab and biosimilar (bs) DMARDs) and targeted synthetic (ts) DMARDs (the Janus kinase (JAK) inhibitors tofacitinib, baricitinib, filgotinib, upadacitinib). Guidance on monotherapy, combination therapy, treatment strategies (treat-To-Target) and tapering on sustained clinical remission is provided. Cost and sequencing of b/tsDMARDs are addressed. Initially, MTX plus GCs and upon insufficient response to this therapy within 3 to 6 months, stratification according to risk factors is recommended. With poor prognostic factors (presence of autoantibodies, high disease activity, early erosions or failure of two csDMARDs), any bDMARD or JAK inhibitor should be added to the csDMARD. If this fails, any other bDMARD (from another or the same class) or tsDMARD is recommended. On sustained remission, DMARDs may be tapered, but not be stopped. Levels of evidence and levels of agreement were mostly high. Conclusions These updated EULAR recommendations provide consensus on the management of RA with respect to benefit, safety, preferences and cost.

Original languageEnglish
Pages (from-to)S685-S699
JournalAnnals of the rheumatic diseases
Issue number6
Publication statusPublished - 2020 Jun 1


  • DMARDs (biologic)
  • DMARDs (synthetic)
  • economic evaluations
  • rheumatoid arthritis
  • treatment

ASJC Scopus subject areas

  • Rheumatology
  • Immunology and Allergy
  • Immunology
  • General Biochemistry,Genetics and Molecular Biology


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