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Table 1 General assumptions and recommendations of the SBR for the drug treatment of RA in Brazil

From: Recommendations of the Brazilian Society of Rheumatology for the use of JAK inhibitors in the management of rheumatoid arthritis

General assumptions

1. The treatment of RA patients should preferably have a multidisciplinary approach, coordinated by a rheumatologist

Degree of agreement: 9.9

2. Treatment of RA patients should include guidance on lifestyle, strict control of comorbidities and vaccination card updates

Degree of agreement: 9.9

3. The treatment of RA patients should be based on decisions shared between patients and physicians, after clarification about their disease and available therapeutic options

Degree of agreement: 10

4. The goal of treatment is a persistent state of clinical remission or, when this is not possible, low disease activity

Degree of agreement: 9.9

SBR recommendations for drug treatment of RA

Recommendation 1: First-line treatment should be performed with csDMARDs as soon as the diagnosis of RA is established

Degree of agreement: 9.9

Recommendation 2: Methotrexate should be the first-choice csDMARD

Degree of agreement: 9.8

Recommendation 3: The combination of 2 or more csDMARDs, preferably including methotrexate, can be used as a first-line treatment

Degree of agreement: 9.6

Recommendation 4: After failure of first-line methotrexate therapy, subsequent strategies include combination with another csDMARD, combination with 2 csDMARDs or exchanging MTX for another csDMARD as a monotherapy

Degree of agreement: 9.6

Recommendation 5: After failure of 2 csDMARD regimens, a bDMARD or a tsDMARD can be used, preferably combined with a csDMARD

Note: Carefully consider the use of tsDMARD in populations at risk for major cardiovascular events, thromboembolic and neoplastic events, including patients over 50 (and especially those over 65) with traditional risk factors for cardiovascular disease (particularly current or past smokers).Degree of agreement: 8.6

Recommendation 6: The different bDMARDs combined with methotrexate have similar efficacy; therefore, the choice should take into account the particularities of each medication in terms of safety and cost

Degree of agreement: 9.6

Recommendation 7: The combination of b/tsDMARDs and methotrexate is preferred over the use of b/tsDMARDs as monotherapy. If monotherapy is necessary, consider preferentially the use of tocilizumab or tsDMARDs

Degree of agreement: 9.1

Recommendation 8: The different tsDMARDs have a similar efficacy profile; therefore, the choice should take into account the particularities of each medication in terms of safety and cost. Degree of agreement: 9.7

Recommendation 9: In case of failure of a bDMARD as initial treatment, a second bDMARD or a tsDMARD can be used

Note: Carefully consider the use of tsDMARD in populations at risk for major cardiovascular events, thromboembolic and neoplastic events, including patients over 50 (and especially those over 65) with traditional risk factors for cardiovascular disease (particularly current or past smokers).Degree of agreement: 9.0

Recommendation 10: In case of failure of a tsDMARD, another tsDMARD or a bDMARD may be used

Degree of agreement: 9.4

Recommendation 11: Corticosteroids, preferably in low doses, for the shortest possible time, should be considered in periods of disease activity, after evaluating the relationship between risk and benefit

Degree of agreement: 9.7

Recommendation 12: The possibility of reduction, dose spacing or eventual discontinuation of bDMARDs or tsDMARDs can be considered in patients who are in persistent remission (6 to 12 months of remission), especially when the patient is using a tsDMARD

Degree of agreement: 9.2

  1. Recommendations included in this update: 5, 8, 9, 10 and 12
  2. RA: rheumatoid arthritis; DMARDs: disease-modifying antirheumatic drugs; csDMARDs: conventional synthetic disease-modifying antirheumatic drugs—methotrexate, leflunomide, sulfasalazine and hydroxychloroquine; tsDMARDs: targeted synthetic disease-modifying antirheumatic drugs—baricitinib, tofacitinib and upadacitinib; bDMARDs: biological disease-modifying antirheumatic drugs; bDMARDs: biological disease-modifying antirheumatic drugs that include: tumor necrosis factor inhibitor (TNFi), i.e., adalimumab, certolizumab, etanercept, golimumab and infliximab, and drugs with other non-TNFi mechanisms of action, i.e., abatacept, rituximab and tocilizumab; NSAIDs: nonsteroidal antiinflammatory drugs; Remission: remission according to ACR/EULAR criteria