Streamlining options for clinical practice
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In 2022, EULAR – The European Alliance of Associations for Rheumatology – updated its recommendations on the treatment of rheumatoid arthritis (RA) with disease-modifying antirheumatic drugs (DMARD). The 2025 update again takes in new evidence in the field.

First published in 2010, the EULAR recommendations for the management of RA, the most frequent inflammatory rheumatic disease, have been relied upon by healthcare professionals and organisations worldwide to offer an up-to-date and robust analysis of the effectiveness and practical use of available DMARDs – from conventional agents such as methotrexate to biologics and Janus kinase (JAK) inhibitors. The recommendations were last reviewed in 2022 to include key safety factors. The current fifth update was again based on reviews of the most recent evidence regarding these therapies and provides the most up-to-date guidance. Although there have been no new drugs approved since the last version, deepened insights as well as important strategic developments have accumulated.

Researchers, healthcare professionals, and patients from around the world worked together to develop this new advice. Of note, there are now fewer recommendations – a total of 9, down from 11 in the 2022 version – with one previous recommendation being removed, and two merged. This is the smallest number of recommendations in the 15-year history of this guidance document, helping to further simplify the clinical approach – and, as previously, the insights have been condensed into a graphic algorithm.

The new work, published online on March 2026 on the website of Annals of the Rheumatic Diseases, includes five overarching principles and nine individual recommendations. The overarching principles state – as in earlier iterations – that rheumatologists are the specialists who should primarily care for people with RA. They also restate the aim for best care, which includes shared decision-making between the patient and the rheumatologist based on disease activity and safety as well as patient factors such as comorbidities or progression of structural damage. There are multiple drugs with different modes of action, and people may require multiple successive therapies throughout their life to control their disease. Finally, RA has a high individual, medical, and societal cost, all of which should be considered in its management.

The recommendations reiterate that DMARDs should be started as soon as the diagnosis of RA is made. They go on to consider treatment targets and monitoring frequency, as well as the specific role for methotrexate, glucocorticoids, biologics, and JAK inhibitors – the only group of targeted synthetic DMARDs approved for RA – including what to do if treatment targets are not achieved, or if a patient is in sustained remission. An important change in the current update is the omission of stratification according to risk factors for bad outcome once the initial treatment strategy has failed, since that failure is already such a risk factor. While the authors acknowledge the developing field around pre-RA, this has not yet matured to allow for a respective new recommendation.

“In the last 15 years EULAR has provided the support to assemble one of the largest task forces in the field with experts from across the globe, allowing the development of recommendations for the management of RA that include important and highly valuably international input” said Josef Smolen – convenor of the task force, Editor-in-Chief of ARD and Professor emeritus at the Medical University of Vienna in Austria. “Informed by thorough assessment of the most recent research activities, the new recommendations continue to be at the forefront of guidance for clinical practice and approaches to future scientific developments.”

Also of note, the previous recommendations advised that, after glucocorticoids had been discontinued and a patient was in sustained remission, DMARD dose reduction could be considered;¹ the new formulation adds in a preference for DMARD continuation in this situation, although dose reduction may still be considered.

“A cure for RA is still rare, and for most patients stopping treatment altogether leads to the disease flaring, especially for patients on biologic or JAK inhibitor therapies” said Christopher Edwards – co-convenor of the task force, EULAR board member and Professor at the University of Southampton, United Kingdom. “While carefully reducing medication can be successful for some people, completely stopping treatment is generally not advised. The updated recommendations continue to highlight that treatment decisions should be made jointly by patients and clinicians, ensuring that care is tailored to each individual’s needs and preferences.”

EULAR hopes the updated and streamlined recommendations will support therapeutic decisions for people living with RA.

Source
Smolen JS, Edwards CJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biologic disease modifying antirheumatic drugs: 2025 update. Ann Rheum Dis 2026; doi.org/10.1016/j.ard.2026.01.023

References
1. Smolen JS, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis 2023 Jan;82(1):3–18. doi: 10.1136/ard-2022-223356

About EULAR
EULAR is the European umbrella organisation representing scientific societies, health professional associations and organisations for people with rheumatic and musculoskeletal diseases (RMDs). EULAR aims to reduce the impact of RMDs on individuals and society, as well as improve RMD treatments, prevention, and rehabilitation. To this end, EULAR fosters excellence in rheumatology education and research, promotes the translation of research advances into daily care, and advocates for the recognition of the needs of those living with RMDs by EU institutions.

Contact
EULAR Communications, communications@eular.org