Fig. 1

Flowchart - 2017 Recommendations of the Brazillan Society of Rheumatology for pharmacological treatment of rheumatoid arthritis.

1: Sulfasalazine or leflunomide may be used in cases of contraindication to MTX. Antimalarials (hydroxychloroquine or chloroquine) as monotherapy may be considered in cases of low probability of development of radiographic erosions. 2: The most used combinations in Brazil are MTX + antimalarials, MTX + leflunomide (with or without antimalarials), MTX + sulfasalazine (with or without antimalarials). 3: The goal of treatment is remission according to ACR/EULAR criteria or, in cases where this is not possible, low disease activity, as assessed by one of the composite disease activity indices defined in the 2011 SBR Consensus (5). 4: The use of a third TNFi after failure of two TNFi drugs is not recommended. 5: In Brazil, rituximab is recommended in combination with methotrexate for patients with a poor response or intolerance to one or more TNFi drugs. 6: In case of failure or toxicity to a drug used in the third line of treatment, the next step is switching to another drug (bDMARD or tsDMARD) with the same level of complexity and that has not been used previously