Rheumatoid arthritis
Also known as: RA
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2021 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis
American College of Rheumatology (ACR) · 2021 · 2021 guideline
The ACR's guideline landing page hosts the current US recommendations on drug treatment of rheumatoid arthritis, covering conventional synthetic, biologic and targeted synthetic DMARDs, glucocorticoid use, and treatment in selected higher-risk patient groups. Recommendations were graded with GRADE methodology, and the page also archives the earlier 2015, 2012 and 2008 documents.
EULAR recommendations for the management of rheumatoid arthritis with synthetic and biologic disease-modifying antirheumatic drugs: 2025 update
European Alliance of Associations for Rheumatology (EULAR) · 2026 · 2025 update
The European recommendations on pharmacological management of rheumatoid arthritis, revised by an international EULAR task force and published in Annals of the Rheumatic Diseases. The update restructures the previous set into a smaller number of recommendations covering sequencing of conventional synthetic DMARDs, biologics and JAK inhibitors, glucocorticoid use, and tapering once disease is controlled.
- Published in Annals of the Rheumatic Diseases in 2026 (volume 85, issue 6), led by a task force chaired by Josef S. Smolen. source
- Addresses safety considerations such as cardiovascular events, malignancy and thromboembolism when positioning JAK inhibitors relative to biologic DMARDs. source
- Covers tapering of therapy in sustained remission and warns that full discontinuation is often followed by flare. source
US vs EU key differences
- Glucocorticoid bridging is the sharpest divergence: the 2021 ACR guideline conditionally recommends against adding short-term glucocorticoids when DMARDs are started in moderate-to-high disease activity, whereas EULAR keeps methotrexate plus short-term glucocorticoids as the explicit first treatment strategy, tapered off as fast as clinically feasible. source
- Treatment target differs in emphasis: ACR conditionally suggests aiming first for low disease activity and considering remission later, while EULAR keeps remission as the primary target for all patients and treats low disease activity as an alternative mainly in long-standing disease. source
- Version currency differs by four years: the US guideline dates to 2021, while EULAR issued a 2025 update that condensed the document from 11 recommendations to 9 alongside 5 overarching principles. source
- Both sides agree on methotrexate as the anchor first csDMARD and on escalating to a b/tsDMARD if the target is not reached at roughly 3-6 months, with leflunomide or sulfasalazine as alternatives where methotrexate is contraindicated. source
What changed recently
- EU2022 update → 2025 update2026-06-01
The task force consolidated the guidance from 11 recommendations down to 9 by merging and deleting items, while keeping methotrexate plus short-term glucocorticoids as the first step and adding a biologic DMARD after 3-6 months of inadequate response. Safety framing was sharpened, with JAK inhibitors requiring explicit assessment of cardiovascular and malignancy risk before use.
source ↗curation confidence 90% - US2015 guideline → 2021 guideline2021-06-08
The 2021 guideline reversed the earlier acceptance of low-dose prednisone as bridging therapy, advising against it because patients frequently stay on steroids far longer than intended, and it reaffirmed methotrexate as the anchor drug while conditionally preferring hydroxychloroquine or sulfasalazine for low disease activity. It also added new topics absent from 2015, including methotrexate use in pulmonary disease and fatty liver disease, and treatment alongside nontuberculous mycobacterial lung infection.
source ↗curation confidence 90%
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