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Table 3 General principles and recommendations of the Brazilian Society of Rheumatology for pharmacological treatment of rheumatoid arthritis in Brazil

From: 2017 recommendations of the Brazilian Society of Rheumatology for the pharmacological treatment of rheumatoid arthritis

General principles
 General principle 1: Treatment of patients with RA should preferably consist of a multidisciplinary approach coordinated by a rheumatologist.
 Level of agreement: 9.87
 General principle 2: RA treatment should include counseling on lifestyle habits, strict control of comorbidities, and updates of the vaccination record.
 Level of agreement: 10
 General principle 3: RA treatment should be based on decisions shared by the patient and physician after clarification about the disease and the available therapeutic options.
 Level of agreement: 9.93
 General Principle 4: The goal of RA treatment is sustained clinical remission or, when this is not feasible, low disease activity.
 Level of agreement: 9.87
Recommendations for drug treatment of RA
 Recommendation 1: The first line of treatment should be a csDMARD, started as soon as the diagnosis of RA is established.
 Level of agreement: 9.93
 Recommendation 2: Methotrexate is the first-choice csDMARD.
 Level of agreement: 10
 Recommendation 3: Combination of two or more csDMARDs, including methotrexate, may be used as the first line of treatment.
 Level of agreement: 9.62
 Recommendation 4: After failure of first-line therapy with MTX, the therapeutic strategies include combining MTX with another csDMARD (leflunomide), with two csDMARDs (hydroxychloroquine and sulfasalazine), or switching MTX for another csDMARD (leflunomide or sulfasalazine) alone.
 Level of agreement: 9.12
 Recommendation 5: After failure of two schemes with csDMARD, a bDMARD may be preferably used or, alternatively, a tsDMARD, preferably combined, in both cases, with a csDMARD.
 Level of agreement: 9.5
 Recommendation 6: The different bDMARDs in combination with MTX have similar efficacy, and therefore, the therapeutic choice should take into account the peculiarities of each drug in terms of safety and cost.
 Level of agreement: 9.31
 Recommendation 7: The combination of bDMARD and methotrexate is preferred over the use of bDMARD alone.
 Level of agreement: 9.87
 Recommendation 8: In case of failure of an initial treatment scheme with bDMARD, a scheme with another bDMARD can be used. In cases of failure with a TNFi, a second bDMARD of the same class or with another mechanism of action is effective and safe.
 Level of agreement: 9.37
 Recommendation 9: Tofacitinib can be used to treat RA after failure of bDMARD.
 Level of agreement: 9.81
 Recommendation 10: Corticosteroids, preferably at low doses for the shortest possible time, should be considered during periods of disease activity, and the risk-benefit ratio should also be considered.
 Level of agreement: 9.81
 Recommendation 11: Reducing or spacing out bDMARD doses is possible in patients in sustained remission.
 Level of agreement: 9.31
  1. csDMARD: Conventional synthetic disease-modifying antirheumatic drugs (methotrexate, leflunomide, sulfasalazine) and antimalarials (hydroxychloroquine and chloroquine)
  2. tsDMARD: Synthetic target-specific disease-modifying antirheumatic drugs – tofacitinib
  3. bDMARD: biological disease-modifying drugs – tumor necrosis factor inhibitors/TNFi (adalimumab, certolizumab, etanercept, golimumab, infliximab), T-lymphocyte costimulation modulator (abatacept), anti-CD20 (rituximab), and IL-6 receptor blocker (tocilizumab)