Choosing Wisely:

Don’t prescribe biologics for rheumatoid arthritis before a trial of methotrexate (or other conventional nonbiologic disease-modifying antirheumatic drugs [DMARDs]).

Rationale and Comments: High-quality evidence suggests that methotrexate and other conventional nonbiologic DMARDs are effective in many patients with rheumatoid arthritis. Initial therapy for rheumatoid arthritis should be a conventional nonbiologic DMARD unless these are contraindicated. If a patient has had an inadequate response to methotrexate with or without other nonbiologic DMARDs during an initial three-month trial, then biologic therapy can be considered. Exceptions include patients with high disease activity AND poor prognostic features (functional limitations, disease outside the joints, seropositivity, or bony damage), where biologic therapy may be appropriate first-line treatment.
Sponsoring Organizations:
  • American College of Rheumatology
  • Sources:
  • American College of Rheumatology guidelines
  • Disciplines:
  • Rheumatologic
  • References: • Singh JA, et al. 2012 update of the 2008 American College of Rheumatology recommendations for the use of disease-modifying antirheumatic drugs and biologic agents in the treatment of rheumatoid arthritis. Arthritis Care Res (Hoboken). 2012;64(5):625-39.
    • Smolen JS, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs. Ann Rheum Dis. 2012;69(6):964-75.

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