Intra-articular glucocorticoid injections are often used as an alternative or adjunct to systemic glucocorticoid therapy. They this website can alleviate the local symptoms and inflammation and induce few side effects [71]. In patients with an inadequate response or intolerance to methotrexate and: • presence of adverse prognostic factors, add-on biologic therapy may be considered (TNFα

antagonist, abatacept, tocilizumab or, in specific situations, rituximab2); This recommendation differentiates two strategies based on the prognostic factors. Outcome prediction relies in particular on the combination of the following criteria: presence or progression of structural damage (the main criterion), marked clinical and/or laboratory activity, and high titers of rheumatoid factors and/or ACPA [72], [73], [74] and [75]. In patients with an inadequate response or intolerance to methotrexate but no factors of adverse prognostic significance, the recommended treatment is either combined synthetic DMARD therapy

(e.g., methotrexate + sulfasalazine + hydroxychloroquine) or substitution buy SCH772984 of another synthetic DMARD for the methotrexate. The role for combination synthetic DMARD therapy was recently a focus of controversy, as discussed in part in recommendation #6 (Section 3.2.2.1). The task force considered that the triple drug combination should not be used for the first-line treatment of RA but is supported by recent data for the second-line treatment of patients who have no factors of adverse prognostic significance. A suggested alternative consists in switching to another synthetic DMARD used alone [76]. In patients with factors of adverse Staurosporine prognostic significance (structural damage, marked clinical and/or laboratory activity, high RF and/or ACPA titers), add-on biological therapy can be considered. The biologics licensed for use in this

indication are TNFα antagonists (four given subcutaneously, namely, adalimumab, certolizumab-pegol, etanercept, and golimumab; and infliximab, given as intravenous infusions), the interleukin 6-receptor antagonist tocilizumab, et the T-cell co-stimulation modulator abatacept. All these biological agents have been proven effective in alleviating the symptoms and slowing structural disease progression in patients with RA refractory to methotrexate [9] and [77]. The task force was unable to identify one of these biologics as preferable over the others, since the efficacy and safety profiles were similar in several meta-analyses and a few head-to-head trials; and since no factors predicting the response to a given biologic are available to date for guiding drug selection [78], [79] and [80].