EULAR specifies therapy recommendations for rheumatoid arthritis
22.07.2022 17:10
The treatment of rheumatoid arthritis is continually being developed. Newer findings on the tolerability of previously prescribed rheumatism medications have now led to a revision of the therapy recommendations of the European Alliance of Associations for Rheumatology (EULAR): In order to minimize the cardiovascular risk for patients, glucocorticoids should only be used in very low doses and for a limited time be used. EULAR also provides new application instructions for the drug group Janus kinase inhibitors. The German Society for Rheumatology (DGRh) welcomes the adaptation of the EULAR recommendations.
By the time rheumatoid arthritis (RA) is diagnosed, those affected are often already suffering from severe symptoms: joints throughout the body are painfully inflamed and the quality of life is significantly reduced. Because the effect of basic therapy with so-called conventional, synthetically produced DMARDs (Disease Modifying Anti-Rheumatic Drugs) such as methotrexate is delayed, these are initially combined with glucocorticoids (cortisone preparations). These quickly suppress the inflammation, relieve the symptoms of the disease immediately and thus bridge the time until the basic medication takes effect. “However, glucocorticoids have a wide range of possible undesirable effects, especially if they are taken over a long period of time or in large quantities,” says Prof. Dr. med. Andreas Krause, chief physician at the Immanuel Hospital Berlin and President of the DGRh. “With regard to cardiovascular events - i.e. those affecting the heart and vascular system - these include heart attacks, strokes, high blood pressure and thrombosis.” Rheumatologists therefore pay great attention to only dosing glucocorticoids for as short a time as possible and as low as necessary. This is now further specified in the EULAR recommendations. The current recommendation from EULAR (2022) to taper off glucocorticoid therapy that has been initiated has been tightened compared to the previous recommendation from 2019 in that glucocorticoids should not only be reduced as quickly as possible, but should also be reduced and then discontinued. This revised recommendation agrees with the DGRh guidelines, which already recommended in 2018 that glucocorticoid therapy should be limited to three to six months. “This implies that even very low doses of less than five milligrams per day should not be given as long-term therapy, but should be further reduced and discontinued,” says Krause. Not only the daily amount of glucocorticoids taken over time, but also the total amount of glucocorticoids taken over time is crucial for the cardiovascular risk.
EULAR has also updated the recommendations on the so-called Janus kinase inhibitors (JAK inhibitors). This still young group of synthetically produced DMARDs (tsDMARDs) blocks the enzymes of the Janus kinase family that are important for inflammatory processes. “Some contradictory study results have been published on these active ingredients in recent months,” says Krause. In particular, the ORAL surveillance study commissioned by the US FDA raised questions about the safety of the JAK inhibitor tofacitinib in patients with an increased cardiovascular risk. Over 4,300 patients with RA and over the age of 50 took part in the study. Study participants who received tofacitinib were slightly more likely to have serious cardiovascular events - such as heart attacks or strokes - than in a comparison group of patients treated with a TNF blocker. Lung cancer was also slightly more common with tofacitinib. “However, we do not see these effects in register data,” emphasizes Krause, referring to a recently published evaluation of the German RABBIT register. Here, taking JAK inhibitors was not associated with a higher cardiovascular risk.
The EULAR recommendation does not generally advise against JAK inhibitors. According to EULAR, they can continue to be given in their traditional area of application – as second-line therapy when conventional DMARDs do not respond adequately. When weighing up the use of biologics, the relevant risk factors (including cardiovascular and infectious risk factors) must be given particular consideration.
“Such individual risk factors play an important role in every treatment decision,” says PD Dr. med. Jan Leipe, head of the rheumatology section at the Mannheim University Hospital. This also applies to other risks and comorbidities that occur more frequently in RA patients, such as osteoporosis, infections, cancer or depression, says Leipe, who coordinates the development of the new DGRh guidelines on cardiovascular comorbidities in inflammatory rheumatic diseases. In general, it is important to identify individual risk factors, inform patients about their importance for RA therapy and come to a treatment decision together. “Patients respond differently to drug therapies, and the side effects also differ,” adds DGRh President Krause. This results in personal preferences that should be taken into account when choosing treatment - because, last but not least, adherence to therapy is also crucial for how well the disease and possible complications can be controlled. It is therefore very welcome that the new EULAR recommendations essentially maintain freedom of treatment.
Literature:
Meissner Y, Albrecht K, Kekow J, et al. OP0135 RISK OF CARDIOVASCULAR EVENTS UNDER JANUS KINASE INHIBITORS IN PATIENTS WITH RHEUMATOID ARTHRITIS: OBSERVATIONAL DATA FROM THE GERMAN RABBIT REGISTER Annals of the Rheumatic Diseases 2022;81:86-87.
RHEUMATOLOGY TODAY FROM EULAR 2022, Prof. Dr. med. Thorsten Witte, news from RA therapy, https://medtoday.de/congresses/eular-22/home (accessed July 4, 2022)