Rheumatology · EULAR

Rheumatoid arthritis

EULAR

Source:EULAR Recommendations for the Management of Rheumatoid Arthritis with Synthetic and Biological Disease-Modifying Antirheumatic Drugs (2022 update)

Verified Apr 2026

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Red Flags

Acute hot swollen joint with fever — joint aspiration to exclude septic arthritis; do not assume RA flare^[1]
Severe RA flare with constitutional symptoms, vasculitis, scleritis, or interstitial lung disease — same-day rheumatology^[1]
Latent TB or prior TB exposure starting biologic or JAK inhibitor — IGRA/Mantoux + chest X-ray; treat latent TB before starting^[1]
JAK inhibitor signal: increased CV events, malignancy, VTE in patients ≥65 with risk factors — review indication and consider alternatives^[1]

First-line treatment

Interventions

Phase 1: methotrexate + short-term glucocorticoid^[1]
Start methotrexate at diagnosis (with folic acid); add short-term glucocorticoid bridge (taper within 3 months). Reassess at 3 months and aim remission or low disease activity at 6 months
Phase 2: add biologic or targeted synthetic DMARD if Phase 1 fails^[1]
Add anti-TNF, IL-6 inhibitor, or JAK inhibitor (with caution per safety signals) to methotrexate. Consider patient factors (age, comorbidity, infection risk, CV risk) in agent choice
Phase 3: switch class if Phase 2 fails^[1]
Switch to a different mechanism of action; rituximab, abatacept, IL-6 inhibitor (if not used), or JAK inhibitor; consider drug levels, anti-drug antibodies
Treat-to-target with regular reassessment^[1]
Aim remission or low disease activity (DAS28 <2.6 or <3.2); reassess every 1–3 months early, every 3–6 months once stable; escalate or switch if target not met; consider tapering once sustained remission

First-line drug therapy

Drug	Class	Adult	Paediatric	Notes
Methotrexate^[1]	Conventional synthetic DMARD (anti-folate)	Start 10–15 mg PO/SC weekly with folic acid 5 mg weekly (different day); titrate to 25 mg weekly	—	First-line per EULAR; SC route improves bioavailability; LFT and FBC monitoring; alcohol restriction; teratogen
Glucocorticoid (bridge therapy)^[1]	Systemic corticosteroid	Prednisolone 30 mg PO daily tapering to 7.5 mg over 8 weeks then off by 3 months	—	Bridge while DMARD takes effect; minimise duration to <3 months; bone protection (calcium, vitamin D, bisphosphonate per fracture risk)
Anti-TNF (etanercept, adalimumab, infliximab, certolizumab, golimumab)^[1]	TNF-alpha inhibitor (biologic)	Etanercept 50 mg SC weekly; adalimumab 40 mg SC every 2 weeks; infliximab 3 mg/kg IV at 0, 2, 6 weeks then every 8 weeks	—	Add when methotrexate inadequate; latent TB and HBV screen; certolizumab preferred in pregnancy (no placental transfer); biosimilars widely available
Tocilizumab or sarilumab^[1]	IL-6 receptor inhibitor	Tocilizumab 162 mg SC weekly; sarilumab 200 mg SC every 2 weeks	—	Useful in monotherapy where methotrexate not tolerated; lipid increase, neutropenia, GI perforation risk
Rituximab^[1]	Anti-CD20 monoclonal antibody	1 g IV × 2 doses 2 weeks apart, repeat at 6 months	—	Seropositive RA failing TNF; HBV screen and prophylaxis; vaccinate before; long-lasting immunosuppression
JAK inhibitor (tofacitinib, baricitinib, upadacitinib)^[1]	Janus kinase inhibitor	Tofacitinib 5 mg PO BD; baricitinib 4 mg PO daily; upadacitinib 15 mg PO daily	—	Reserve for second-line; ORAL Surveillance signal — CV events, malignancy, VTE in patients ≥65 with risk factors; latent TB and HBV screen; oral biologic alternative

Methotrexate^[1]

Conventional synthetic DMARD (anti-folate)

Adult: Start 10–15 mg PO/SC weekly with folic acid 5 mg weekly (different day); titrate to 25 mg weekly
Paediatric: —

First-line per EULAR; SC route improves bioavailability; LFT and FBC monitoring; alcohol restriction; teratogen

Glucocorticoid (bridge therapy)^[1]

Systemic corticosteroid

Adult: Prednisolone 30 mg PO daily tapering to 7.5 mg over 8 weeks then off by 3 months
Paediatric: —

Bridge while DMARD takes effect; minimise duration to <3 months; bone protection (calcium, vitamin D, bisphosphonate per fracture risk)

Anti-TNF (etanercept, adalimumab, infliximab, certolizumab, golimumab)^[1]

TNF-alpha inhibitor (biologic)

Adult: Etanercept 50 mg SC weekly; adalimumab 40 mg SC every 2 weeks; infliximab 3 mg/kg IV at 0, 2, 6 weeks then every 8 weeks
Paediatric: —

Add when methotrexate inadequate; latent TB and HBV screen; certolizumab preferred in pregnancy (no placental transfer); biosimilars widely available

Tocilizumab or sarilumab^[1]

IL-6 receptor inhibitor

Adult: Tocilizumab 162 mg SC weekly; sarilumab 200 mg SC every 2 weeks
Paediatric: —

Useful in monotherapy where methotrexate not tolerated; lipid increase, neutropenia, GI perforation risk

Rituximab^[1]

Anti-CD20 monoclonal antibody

Adult: 1 g IV × 2 doses 2 weeks apart, repeat at 6 months
Paediatric: —

Seropositive RA failing TNF; HBV screen and prophylaxis; vaccinate before; long-lasting immunosuppression

JAK inhibitor (tofacitinib, baricitinib, upadacitinib)^[1]

Janus kinase inhibitor

Adult: Tofacitinib 5 mg PO BD; baricitinib 4 mg PO daily; upadacitinib 15 mg PO daily
Paediatric: —

Reserve for second-line; ORAL Surveillance signal — CV events, malignancy, VTE in patients ≥65 with risk factors; latent TB and HBV screen; oral biologic alternative

Safety-net

Take methotrexate exactly as prescribed (weekly, never daily) — daily dosing causes life-threatening toxicity^[1]
Any infection (chest, urinary, dental, skin) — same-day medical review while on biologic or JAK inhibitor; pause therapy and seek antibiotic^[1]
Tell every healthcare worker about your DMARD or biologic — affects infection management and surgery planning^[1]

Referral criteria

All suspected new RA (early arthritis with persistent synovitis ≥6 weeks)Rheumatology within 4–6 weeks^[1]
Failure of methotrexate at adequate dose and durationRheumatology for biologic/JAK inhibitor consideration^[1]
Extra-articular RA (vasculitis, scleritis, interstitial lung disease, neurological)Subspecialty co-management^[1]
Pregnancy planning on RA medicationJoint rheumatology and obstetric pre-conception clinic^[1]

Clinical summary

EULAR-aligned treat-to-target conventional, biological, and targeted synthetic DMARD pathway for adults with rheumatoid arthritis.

References

1.EULAR Recommendations for the Management of Rheumatoid Arthritis with Synthetic and Biological Disease-Modifying Antirheumatic Drugs (2022 update) (2022)

Drug

Class

Adult

Paediatric

Notes