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Got useful knowledge again!
To this day, rheumatoid arthritis (RA) remains an incurable disease, but scientists have never given up on exploring
a treatment for RA.
In recent years, the treatment of RA is no longer limited to the traditional synthesis of anti-rheumatic drugs (csDMARDs), biologics DMARDs (bDMARDs), small molecule targeted DMARDs (tsDMARDs) JAK1/2 inhibitors and other new drugs, providing more treatment options
for RA patients.
In this regard, Professor Li Ru from the Department of Rheumatology and Immunology of Peking University People's Hospital and the medical community specially produced this issue of the course "Advances in Rheumatoid Arthritis Research - EULAR 2022" to share with us the latest recommendations
for the treatment of RA in the 2022 European Union Against Rheumatism (EULAR) guidelines.
1
2022 EULAR RA Treatment Guidelines Update Table 1 2022 EULAR RA Treatment Guidelines UpdateGuidelines Other Points:
1.
Once RA is diagnosed, DMARDs should be started immediately (A).
2.
Should aim for sustained remission or low disease activity (A).
3.
Active disease should be monitored every 1-3 months: if there is no improvement for more than 3 months, or if the target is not met for 6 months, the treatment strategy should be adjusted (B).
4.
Methotrexate (MTX) should be part of the preferred treatment regimen (A).
5.
MTX contraindications or intolerance, the use of leflunomide or sulfasalazine as part of the (preferred) treatment regimen (A)
may be considered.
6.
If the initial treatment of csDMARDs does not meet the standard, in the absence of adverse prognostic factors, the use of other csDMARDs (D)
should be considered.
2
The latest research progress in RA01
In a JAK inhibitor safety study that included patients with RA >50 years of age with more than one cardiovascular risk (Figure 1 left), major cardiovascular events and tumor events in the tofacitinib group did not meet the non-inferiority endpointcompared with the TNF-α inhibitor group.
This suggests that patients with RA should be aware of cardiovascular disease and tumor risk
when taking tofacitinib.
However, different studies have different conclusions, and another real-world large study, the Corrona study in the United States (Figure 1 right), did not report the difference
in cardiovascular events and tumor event rates in RA patients between the JAK inhibitor treatment group and the TNF-α inhibitor treatment group.
The main difference between the two groups was that RA patients in the tofacitinib group had a higher
probability of developing shingles.
Figure 1 Safety study of JAK inhibitors
02
Safety of bDMARDs versus tsDMARDsA large study (Figure 2) including data from the registries of RA patients in 16 countries found no significant differencein discontinuation rates due to adverse effects between csDMARDs, TNF-α inhibitors, and JAK inhibitors.
Patients with RA at cardiovascular risk had a higher
rate of adverse discontinuation than other patients.
Fig.
2 Results of discontinuation
rate of adverse reactions Another large-sample prospective cohort study compared the risk of tumorigenesis in patients treated with bDMARDs and tsDMARDs (Fig.
3).
At follow-up, 9% of the bDMARDs-treated group developed new tumors, and the time of onset was an average of 4.
5 years after the application of bDMARDs, which was not significantly different
from the JAK inhibitor and TNF-α inhibitor groups.
Figure 3 Tumor risk of bDMARD and tsDMARD
03
The treatment of arthralgia (CSA) with clinical suspicion of developing RA has been studied in patients initiated at the CSA stage and showed no significant difference in overall RA incidence between treatment and placebo groups (Figure 4).However, in high-risk patients (risk of developing RA ≥70%), the risk of RA was suppressed when MTX was used, but the inhibitory effect disappeared
after discontinuation.
Fig.
4 Therapeutic effect on CSA
3
1.
For suspected refractory RA, the possibility of misdiagnosis and/or the presence of similar diseases should be considered first;
2.
According to clinical assessment and comprehensive index to suspect the presence of inflammatory activity, ultrasound examination can be considered;
3.
In the presence of comorbidities, particularly in the presence of obesity and fibromyalgia, the composite index and clinical assessment should be interpreted with caution, as these may directly exacerbate inflammatory activity and/or overestimate disease activity;
4.
Treatment adherence should be discussed and optimized in a shared decision-making process;
5.
After the failure of the second or subsequent b/tsDMARDs, especially after the failure of the second TNFi, the use of b/tsDMARDs with different targets should be considered for treatment;
6.
If third or subsequent b/tsDMARDs are being considered, the maximum dose found to be effective and safe in appropriate studies should be used;
7.
Comorbidities that affect quality of life alone or due to limiting the choice of treatment for RA, which need to be carefully considered and managed;
8.
In patients with HBV/HCV infection, b/tsDMARDs may be used, and concomitant antiviral prophylaxis or treatment should be considered in close cooperation with a hepatologist ;
9.
In addition to pharmacotherapy, non-pharmacological interventions (motor, psychological, educational and self-management interventions) should be considered to optimize the management of functional disability, pain and fatigue;
10.
Patients should be provided with appropriate education and support to directly inform their options for treatment goals and management;
11.
Consider offering self-management options; Relevant educational and psychological interventions to optimize patients' ability to confidently manage the disease (i.
e.
self-efficacy).
Where to see more rheumatology clinical knowledge? Come to the "doctor's station" and take a look 👇
