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ID PMID Title PublicationDate abstract
31749986 Efficacy and safety of topical and systemic medications: a systematic literature review in 2019 OBJECTIVE: To evaluate current evidence on the efficacy and safety of topical and systemic medications in patients with primary Sjögren syndrome (SjS) to inform European League Against Rheumatism treatment recommendations. METHODS: The MEDLINE, EMBASE and Cochrane databases were searched for case-control/prospective cohort studies, randomised controlled trials (RCTs) and systematic reviews. RESULTS: Current evidence in primary SjS patients fulfilling the 2002 criteria is based on the data from 9 RCTs, 18 prospective cohort studies and 5 case-control studies. Two Cochrane systematic literature reviews (SLRs) have reported that topical treatments for dry mouth and dry eye are safe and effective. Ocular cyclosporine A was safe and effective in two RCTs including 1039 patients with dry eye syndrome. Two Cochrane SLRs on serum tear drops and plugs showed inconsistency in possible benefits, both for symptoms and objective measures. Five RCTs reported significant improvements in oral dryness and salivary flow rates for pilocarpine and cevimeline. An RCT showed no significant placebo-differences for hydroxychloroquine 400 mg/day for the primary outcome (visual analogue scale (VAS) composite of dryness, fatigue and pain). We identified seven RCTs carried out in primary SjS patients. RCTs using infliximab, anakinra and baminercept found no placebo-differences for the primary outcomes. The two largest RCTs randomised 255 patients to receive rituximab or placebo and reported no significant results in the primary outcome (VAS composite), while prospective studies suggested efficacy in systemic disease. CONCLUSION: The current evidence supporting the use of the main topical therapeutic options of primary SjS is solid, while limited data from RCTs are available to guide systemic therapies.
31667756 Treat-To-Target and Treat-To-Budget in Rheumatoid Arthritis: Measuring the Value of Indivi 2019 Dec Treat-to-target (T2T) and dose tapering after obtaining the therapeutic objective (called "treat-to-budget"-T2B-in this Commentary) are the two most commonly used therapeutic strategies in rheumatoid arthritis. In theory, both strategies could add value to the healthcare system, although they are focused on different objectives: T2T strategy improves outcomes but increases short-term costs, while the cost savings obtained through T2B are associated with higher relapse rates. The systematic implementation of both strategies must be founded on solid evidence of their effectiveness and efficiency. However, the level of evidence between guidelines and individual studies is inconsistent for both strategies and the number and the quality of cost-effectiveness analyses is scarce. Raising the level of evidence requires a move from generalization to individualization by conducting randomized clinical trials that assess each of the many strategies that fall under the umbrella of the overall T2T and T2B concepts. In addition, such studies should consider the therapeutic goals and impact of the disease from the perspective of individual patients, which is only possible by promoting shared decision-making. FUNDING: Lilly Spain.
31417683 Types of pain and their psychosocial impact in women with rheumatoid arthritis. 2019 Rheumatoid arthritis (RA) is a systemic inflammatory autoimmune disease predominantly affecting middle-aged women. Very commonly, pain is a manifestation of active disease and because untreated RA can result in joint deformities, the current evaluation of pain has largely focused on inflammation. In addition, treatment has centered on the premise of reducing disease activity with the hopes of halting worsening damage, preventing future deformities, and ultimately providing pain relief for the patient. Yet research shows that all patients with RA, but women in particular, often suffer from increased mechanical pain and fibromyalgia, as well as anxiety, depression, sleep disturbances, sexual dysfunction, and disability, which add to the burden of the illness. Determining and addressing alternative pain triggers as well as understanding the psychosocial burden of RA is key in treating patients, especially in those who may not improve with traditional pharmacotherapy.
31608186 Reconsidering the Use of Minocycline in the Preliminary Treatment Regime of Rheumatoid Art 2019 Aug 8 Strong epidemiologic, clinical, and basic science studies have identified a number of factors that may lead to rheumatoid arthritis (RA) onset and progression, particularly involving the complex interplay between genomics, environmental risk factors, the breakdown of immune self-tolerance, and microbiome dysbiosis. A chronic state of inflammation established by infectious agents has long been suspected to set the stage for the development of RA. The purpose of this article is to review the contribution of the gut, lung, and oral microbiomes to the pathogenesis of RA and consider the importance of supplementing the preliminary treatment regime of RA patients with antibiotics, in particular, minocycline. Minocycline has been used in the treatment of RA due to its bacteriostatic, as well as immunomodulatory and anti-inflammatory properties. Ultimately, a short course of antibiotic treatment with minocycline may eliminate pathogenic organisms contributing to the development and progression of RA.
31049848 Shared Decision-Making and Patient Satisfaction in Japanese Rheumatoid Arthritis Patients: 2019 Jun INTRODUCTION: We have developed a new framework to assess shared decision-making (SDM) as a tool to improve patient satisfaction. This framework is based on a "preference fit" index that relates SDM to patient treatment preferences and patient satisfaction in a sample of rheumatoid arthritis (RA) patients in Japan. METHODS: We surveyed 500 RA patients in Japan and explored the interactions between the treatment preference fit index, SDM, and overall patient satisfaction. RESULTS: Our new preference fit index reveals significant impact on patient satisfaction: the better the fit between SDM and patient preferences, the higher the patient satisfaction with the current treatment. Patients treated with biologic agents were more satisfied. Patients suffering from depression or migraines scored significantly lower both on our preference fit measure and for overall patient satisfaction. CONCLUSION: The association between depression and a low treatment preference fit suggests that depression may pose challenges to SDM and that doctors in Japan are less attuned to the SDM preferences of depressed patients. FUNDING: Janssen Pharmaceutical KK.
31031880 The Effect of Auricular Plaster Therapy on Insomnia in Patients with Rheumatoid Arthritis. 2019 Apr 1 Objective: This research was conducted to observe the effects of auricular plaster therapy on insomnia in patients with rheumatoid arthritis (RA). Materials and Methods: This study involved 76 patients with insomnia caused by RA, who were admitted to Foshan Chancheng Central Hospital-in Foshan, Guangdong, China-from August 2017 to August 2018. The patients were randomized, with 38 to the intervention group and another 38 to the control group. The intervention group was treated with auricular plaster therapy with beans, while the control group was treated with estazolam orally before going to bed. Curative effects were compared between the 2 groups. The Pittsburgh Sleep Quality Index scale (PSQI) and the Athens Insomnia Scale (AIS) were used to assess and evaluate the sleep quality of patients. Result: Scores of the PSQI dimensions all fell in both groups after treatment. Scores for sleep quality, sleep latency, sleep efficiency, sleep disorder, and daytime dysfunction in the observation group were lower than those in the control group (P < 0.05). AIS scores in all dimensions decreased in both groups, and, after treatment, scores and total points of sleep latency, night-time revival, overall sleep quality, and the dimensionality of daytime body function in the intervention group were lower than those in the control group (P < 0.05). Conclusions: Auricular plaster therapy has a marked effect on insomnia in patients with RA, and the therapy is easy and simple to apply.
30907316 Systemic and CNS Inflammation Crosstalk: Implications for Alzheimer's Disease. 2019 After years of failed therapeutic attempts targeting beta-amyloid (Aβ) in AD, there is now increasing evidence suggesting that inflammation holds a pivotal role in AD pathogenesis and immune pathways can possibly comprise primary therapeutic targets. Inflammation is a key characteristic of numerous diseases including neurodegenerative disorders and thus not surprisingly suppression of inflammation frequently constitutes a major therapeutic strategy for a wide spectrum of disorders. Several brain-resident and peripherally-derived immune populations and inflammatory mediators are involved in AD pathophysiology, with microglia comprising central cellular player in the disease process. Systemic inflammation, mostly in the form of infections, has long been observed to induce behavioral alterations and cognitive dysfunction, suggesting for a close interaction of the peripheral immune system with the brain. Systemic inflammation can result in neuroinflammation, mainly exhibited as microglial activation, production of inflammatory molecules, as well as recruitment of peripheral immune cells in the brain, thus shaping a cerebral inflammatory milieu that may seriously impact neuronal function. Increasing clinical and experimental studies have provided significant evidence that acute (e.g. infections) or chronic (e.g. autoimmune diseases like rheumatoid arthritis) systemic inflammatory conditions may be associated with increased AD risk and accelerate AD progression. Here we review the current literature that links systemic with CNS inflammation and the implications of this interaction for AD in the context of acute and chronic systemic pathologies as acute infection and rheumatoid arthritis. Elucidating the mechanisms that govern the crosstalk between the peripheral and the local brain immune system may provide the ground for new therapeutic approaches that target the immune-brain interface and shed light on the understanding of AD.
31058152 Synovial Tissue Biopsy Research. 2019 Synovial tissue is a key structure in diarthrodial joints and is the primary target of inflammation in autoimmune arthritis. The study of synovial tissue has developed significantly in the last two decades as arthroscopic and ultrasonographic techniques have allowed visualization and access to synovial biopsy. Further progress in synovial tissue processing and analysis has improved studies of disease pathogenesis, biomarker discovery, and molecular therapeutic targeting with increasingly specialized analytical and technological approaches. In September 2018 the first course on Synovial Tissue Biopsies was convened in Brussels, in this Mini Review these approaches will be described and I will summarize how synovial tissue research advanced.
30961644 Synovial tissue biopsy analysis: unlocking the hidden secrets to personalised medicine? 2019 Apr 8 Rheumatoid arthritis is an immune-mediated inflammatory disease of the synovium. Yet we still lack robust tissue-specific (synovial) biomarkers that are able to guide clinical decisions and stratify patients according to their disease subgroup and predicted response to treatment. The EULAR Synovitis Study Group and the OMERACT synovial tissue biopsy (STB) Special Interests Group have undertaken a consensus exercise to identify factors that are important for the standardisation of STB handling and analytical procedures in two situations-clinical practice and translational research.
31871415 Not only anti-inflammation, etanercept abrogates collagen-induced arthritis by inhibiting 2019 The application of tumor necrosis factor inhibitors (TNFi) is a major breakthrough in the treatment of rheumatoid arthritis (RA). While the anti-inflammatory nature of TNFi is thought to contribute to the therapeutic effects, recent data show that the pharmacology of TNF-α blockade is probably more complex than previously thought. This study investigates whether etanercept (ETN), one of the TNF antagonists, suppresses arthritis development through modulation of dendritic cell (DC) functions. Bone marrow-derived DCs (BMDCs) were stimulated with lipopolysaccharide (LPS) and treated with ETN for 24 hrs. DC functions, including maturation and migration, were determined. DCs from the lymph nodes (LNs) of ETN-treated collagen-induced arthritis (CIA) mice were analyzed for phenotypes and subsets. ETN efficiently inhibited the phenotypic maturation both in vitro and in vivo. ETN treatment delayed the onset and reduced the severity of arthritis in CIA mice. Moreover, ETN treatment strongly down regulated the number of both myeloid DCs (mDCs) and plasmacytoid DCs (pDCs) in LNs, possibly due to the depressive effect on the expression of CXCR4 on DCs in peripheral blood. The impaired DC migration to local LNs by ETN down regulated the number of T cells and B cells, and changed the LN cellular composition. The data show that TNF-α blockade has profound effects on DC maturation and migration, which may contribute to its immune regulatory effects in RA patients.
30697037 Persistence to subcutaneous biological agents in Hungarian patients treated for inflammato 2019 BACKGROUND: The aim of the study was to compare drug survival rate of subcutaneous tumor necrosis factor alpha inhibitors in rheumatoid arthritis, ankylosing spondylitis, and psoriatic arthritis patients in Hungary. METHODS: This was a retrospective analysis using data collected from 5,647 patients over a period of 10 years who were treated with any of the following drugs: adalimumab (ADA), etanercept, certolizumab pegol (CZP), and golimumab (GLM). National Health Insurance Fund's hospital, drug reimbursement, and special reimbursement registry data have been used in this study. Drug survival rate was calculated according to Kaplan-Meier survival analysis. Propensity score matching was used to reduce the potential bias caused by the inhomogeneity resulting from demographic characteristics, patient pathways, or drug administration protocols. Both raw and propensity matched data were subject of pairwise comparison between the four subcutaneous therapies. RESULTS: The overall rate of persistence for the 4 biological therapies was between 53% and 61% after 1 year and between 14% and 19% after 4 years (follow-up time). Pairwise comparisons between therapies showed significant differences with GLM-treated patients showing longer median survival times than patients on other therapies. After propensity matching, these differences remained statistically significant between GLM and ADA or CZP over 4 years. CONCLUSION: Hungarian show longer persistence to GLM compared to ADA and CZP.
31998313 Syndecan-3 in Inflammation and Angiogenesis. 2019 Syndecans are a four member multifunctional family of cell surface molecules with diverse biological roles. Syndecan-3 (SDC3) is the largest of these, but in comparison to the other family members relatively little is known about this molecule. SDC3 null mice grow and develop normally, all be it with subtle anatomical phenotypes in the brain. Roles for this molecule in both neuronal and brain tissue have been identified, and is associated with altered satiety responses. Recent studies suggest that SDC3 expression is not restricted to neuronal tissues and has important roles in inflammatory disorders such as rheumatoid arthritis, disease associated processes such as angiogenesis and in the facilitation of infection of dendritic cells by HIV. The purpose of this review article is to explore these new biological insights into SDC3 functions in inflammatory disease.
32226165 Effects of whole body cryotherapy in patients with rheumatoid arthritis considering immune 2019 OBJECTIVES: Whole body cryotherapy (WBC) is widely used in inflammatory diseases of the joints, including rheumatoid arthritis (RA), but the mechanism(s) of its action is not fully understood. The aim of the study was to compare the effects of WBC and conventional rehabilitation (CR) on the clinical and immune status of RA patients. MATERIAL AND METHODS: Rheumatoid arthritis patients were classified into 2 groups according to the rehabilitation method used: the study group (CT, n = 25) and control group (CR, n = 25). To measure disease activity, the disease activity score (DAS28) was used, while to assess the morning stiffness and pain intensity, the visual analogue scale (VAS) was applied. Selected laboratory parameters, such as erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels, were also determined. The serum concentrations of pro- (interleukin 6 [IL-6], tumor necrosis factor α [TNF-α], macrophage migration inhibitory factor [MIF]) and anti-inflammatory (IL-10) cytokines were measured to assess the patient's immune status. RESULTS: After rehabilitation disease activity (DAS28), morning stiffness and pain intensity (VAS) decreased in both patient groups and no statistically significant differences were observed between them. However, statistically significant improvement in the CRP serum level was observed in the CT group only. No differences were observed in the serum concentrations of tested cytokines either before and after rehabilitation, or between patient groups. CONCLUSIONS: We report that regardless of the type of therapy, comprehensive rehabilitation improves the patient's clinical status, but has no effect on the levels of circulating cytokines, such as IL-6, IL-10, TNF-α, and MIF, despite significant reduction of a systemic inflammatory marker (CRP), especially in the CT group.
31583550 Ocular manifestations of rheumatic diseases. 2020 Feb PURPOSE: Our aim was to summarize key aspects of the pathomechanism and the ocular involvements of rheumatic and systemic autoimmune diseases. METHODS: Apart from a paper in French (Morax V, Ann Oculist 109:368-370, 1893), all papers referred to in this article were published in English. All the materials were peer-reviewed full-text papers, letters, reviews, or book chapters obtained through a literature search of the PubMed database using the keywords ocular manifestations; pathogenesis; systemic inflammatory rheumatic diseases; rheumatoid arthritis; osteoarthritis; fibromyalgia; systemic lupus erythematosus; seronegative spondyloarthritis; ankylosing spondylitis; reactive arthritis; enteropathic arthritis; psoriatic arthritis; systemic sclerosis; polymyalgia rheumatica and covering all years available. Some statements articulated in this paper reflect the clinical experience of the authors in their tertiary-referral center. RESULTS: Ophthalmic disorders are categorized by anatomical subgroups in all rheumatic diseases. The most common ocular manifestations are diverse types of inflammations of different tissues and dry eye disease (DED). CONCLUSION: The eye could be a responsive marker for the onset or aggravation of an immune reactivation in many rheumatic diseases, furthermore, ocular findings can antedate the diagnosis of the underlying rheumatic disease. By recognizing ocular manifestations of systemic rheumatic diseases it might be possible to avoid or at least delay many long term sequelae.
31777809 Reduced Ovarian Function in Female Rheumatoid Arthritis Patients Trying to Conceive. 2019 Jul OBJECTIVE: Subfertility, a time to pregnancy (TTP) longer than 12 months, is present in 40% of female patients with rheumatoid arthritis (RA) who are actively trying to conceive. Because patients with RA appear to reach menopause at a younger age, diminished ovarian function may explain the reduced fertility. Serum anti-Müllerian hormone (AMH) levels are the best proxy to measure ovarian function. Our objectives were to study AMH levels in female patients with RA and determine the association of preconception serum AMH levels with TTP. METHODS: A post hoc analysis was performed before conception in patients of the Pregnancy-Induced Amelioration of Rheumatoid Arthritis (PARA) cohort. Serum AMH levels were compared with those in an existing cohort of healthy controls using analysis of covariance. Associations between AMH and TTP were studied using the Cox proportional hazard analysis. RESULTS: Preconception serum was available in 209 women of the PARA cohort (aged 32.1 ± 3.9 years), of whom 45% were subfertile in the current episode. The median AMH level was 2.5 μg/l (interquartile range: 1.5-4.6). AMH levels were significantly lower compared with those in healthy controls (P < 0.001), with 17% of patients having levels below the age-specific 10th percentile. A multivariable analysis showed a negative association of AMH with the presence of anticitrullinated protein antibodies (ACPAs) (P = 0.009). AMH levels showed no significant association with TTP (P = 0.26). CONCLUSION: Women with RA have lower AMH levels than healthy controls, and AMH levels were lower in ACPA-positive patients. However, because preconception AMH levels were not associated with TTP, the reduced AMH levels do not explain the reduced fertility in patients with RA.
31143649 Fully automated segmentation of wrist bones on T2-weighted fat-suppressed MR images in ear 2019 Apr BACKGROUND: Magnetic resonance imaging (MRI) allows accurate determination of soft tissue and bone inflammation in rheumatoid arthritis. Inflammation can be measured semi-quantitatively using the well-established RA-MRI scoring system (RAMRIS), but its application is time consuming in routine clinical practice. To fully realize an automated quantitation of inflammation scoring for clinical use, automatic segmentation of the wrist bones on MR imaging is needed. Most previous studies extracted the wrist bones on T1-weighted (T1W) MR images, and then used registration to segment T2W fat-suppressed images for bone marrow oedema quantification, introducing spatial errors into the process. Relatively little work has tried segmentation directly from T2W fat-suppressed images and no prior study have used convolution neural network (CNN) to segment the wrist bones. The purpose of this study is to develop a CNN-based algorithm for automated segmentation of the wrist bones in early rheumatoid arthritis (ERA) patients on T2W fat-saturated MR images. METHODS: As preliminary tests indicated that out-of-the-box segmentation CNN U-net performance was compromised by close apposition of wrist tendons and bone, we separated the volumes prior to segmentation by using classification CNN Inception V3 to group images with similar features. The classified images were then segmented by individually trained U-net. We trained the networks on 40 cases and tested them on 11 cases derived from an MR imaging dataset of 51 patients with varying severity of ERA. RESULTS: We obtained a wrist bone segmentation with an average dice similarity coefficient (DICE) of 0.888±0.014, when compared to a manually drawn label. These results are comparable to existing atlas-based methods. CONCLUSIONS: We have developed a fully automatic method to segment the wrist bones in ERA patients of varying severity directly from T2W fat-suppressed MR images. This compares well with manually drawn labels.
31849544 Oral Health-Related Quality of Life in Patients with Rheumatoid Arthritis. 2019 INTRODUCTION: The assessment of the quality of life (QOL) in rheumatoid arthritis (RA) patients is of great importance for health researchers, health planners, and clinical specialists. Thus, the present study aimed to evaluate the oral health-related quality of life in patients with RA. MATERIALS AND METHODS: In this case-control study, data were collected by two standard questionnaires filled by 80 patients with rheumatoid arthritis and 80 healthy individuals. They were analyzed using independent t-test, chi-square test, Mann-Whitney test, Pearson's correlation coefficient, and Kruskal-Wallis test in SPSS 21. RESULTS: The mean of Health Assessment Questionnaire (HAQ) score in RA patients and control groups was 1.17± 0.89 and 0.35±0.12, respectively, and the mean of General Oral Health Assessment Index (GOHAI) score in patients and control groups was 37.46±9.53 and 53.21±11.35, respectively; 62.5% of the patients got HAQ score more than or equal to 1 (≥1) and 91.2% got GOHAI score less than or equal to 50 (≤50). CONCLUSION: The results of the present study suggested that most of the patients with RA had a poor oral health quality of life. Deterioration of disease and aging decrease the GOHAI and the oral health quality of life of patients.
31258713 Expression and function of miR-155 in rat synovial fibroblast model of rheumatoid arthriti 2019 Jul Rheumatoid arthritis (RA) is a common autoimmune disease characterized by joint synovial inflammation and is a challenge for researchers and clinicians. MicroRNAs (miRNAs/miRs) represent a group of small non-coding RNA molecules that post-transcriptionally regulate mRNA expression and are involved in various diseases, including cancer, autoimmune and metabolic diseases, as well as neurological disorders. In the present study, various experiments were performed to investigate the effects and underlying mechanism of miR-155 in RA using rat synoviocytes induced by lipopolysaccharide (LPS) to model rheumatoid arthritis. It was revealed that synovial fibroblasts exhibited significantly higher miR-155 mRNA levels than the control group. Compared with the RA group, the viability of synovial fibroblasts was significantly decreased in the miR-155 mimics + RA group, but markedly increased in the miR-155 inhibitor + RA group. Compared with that in the RA + NC mimic or RA + NC inhibitor groups, the apoptosis of synovial fibroblasts increased significantly in the miR-155 mimics + RA group, but was significantly decreased in the miR-155 inhibitor + RA group. The miR-155 mimics + RA group exhibited higher expression levels of β-catenin, matrix metalloproteinase 7 and cyclin D1 compared with the miR-155 inhibitor + RA group, and the glycogen synthase kinase protein levels was lower compared with the miR-155 inhibitor + RA group. In brief, it was inferred that the Wnt signaling pathway is involved in the miR-155-associated inhibition of RA synovial fibroblast viability and induction of cell apoptosis. Inhibition of miR-155 may be an effective treatment for RA through regulation of the Wnt signaling pathway to reduce cell apoptosis and enhance cell viability.
31193241 Differentiating Bilateral Symptomatic Hand Osteoarthritis From Rheumatoid Arthritis Using 2019 Mar OBJECTIVE: The purpose of this report is to describe a patient with bilateral symptomatic hand osteoarthritis (OA) originally thought to be rheumatoid arthritis (RA) based on clinical and radiographic features. CLINICAL FEATURES: A 48-year-old woman presented with bilateral hand pain, stiffness, swelling, and redness in the proximal and distal interphalangeal joints of 1 year's duration. Laboratory analysis and plain film radiography were equivocal. These findings necessitated the use of diagnostic ultrasound, which revealed no synovitis or erosions in the joints of the hand, so a diagnosis of bilateral symptomatic hand OA was rendered. INTERVENTION AND OUTCOME: A trial of conservative care consisting of mobilizations, instrument-assisted soft tissue therapy, and laser therapy was given. At 1-month follow-up, the patient regained full pain-free range of motion and strength and returned to complete work activity. CONCLUSION: This case report demonstrated that hand OA can present with nonspecific inflammatory-like clinical features. These findings require further testing, in which case ultrasound imaging may be valuable to differentiate OA from RA. Using ultrasound to make this diagnosis may guide management, with rheumatology referral for RA and conservative care for OA.
31660534 A systematic review of guidelines for managing rheumatoid arthritis. 2019 BACKGROUND: We systematically reviewed current guidelines for managing rheumatoid arthritis (RA) to evaluate their range and nature, assess variations in their recommendations and highlight divergence in their perspectives. METHODS: We searched Medline and Embase databases using the terms 'clinical practice guidelines' and 'rheumatoid arthritis' from January 2000 to January 2017 together with publications of national and international bodies. We included guidelines providing recommendations on general RA management spanning a range of treatments and published in English. We undertook narrative assessments due to the heterogeneity of the guidelines. RESULTS: We identified 529 articles; 22 met our inclusion criteria. They were primarily developed by rheumatologists with variable involvement of patient and other experts. Three dealt with early RA, one established RA and 18 all patients. Most guidelines recommend regular assessments based on the Outcome Measures in Rheumatology core dataset; 18 recommended the disease activity score for 28 joints. Twenty recommended targeting remission; 16 suggested low disease activity as alternative. All guidelines recommend treating active RA; 13 made recommendations for moderate disease. The 21 guidelines considering early RA all recommended starting disease modifying drugs (DMARDs) as soon as possible; methotrexate was recommended for most patients. Nineteen recommended combination DMARDs when patients failed to respond fully to monotherapy and biologics were not necessarily indicated. Twenty made recommendations about biologics invariably suggesting their use after failing conventional DMARDs, particularly methotrexate. Most did not make specific recommendations about using one class of biologics preferentially. Eight recommended tapering biologics when patients achieved sustained good responses. CONCLUSIONS: Five general principles transcend most guidelines: DMARDs should be started as soon as possible after the diagnosis; methotrexate is the best initial treatment; disease activity should be regularly monitored; give biologics to patients with persistently active disease who have already received methotrexate; remission or low disease activity are the preferred treatment target.