What is the primary objective for the treatment of RA?
Advances in Rheumatology volume 61, Article number: 70 (2021) Cite this article Show
AbstractRheumatoid arthritis (RA) is a chronic and autoimmune systemic inflammatory disease that can cause irreversible joint deformities, with increased morbidity and mortality and a significant impact on the quality of life of the affected individual. The main objective of RA treatment is to achieve sustained clinical remission or low disease activity. However, up to 40% of patients do not respond to available treatments, including bDMARDs. New therapeutic targets for RA are emerging, such as Janus kinases (JAKs). These are essential for intracellular signaling (via JAK-STAT) in response to many cytokines involved in RA immunopathogenesis. JAK inhibitors (JAKi) have established themselves as a highly effective treatment, gaining increasing space in the therapeutic arsenal for the treatment of RA. The current recommendations aim to present a review of the main aspects related to the efficacy and safety of JAKis in RA patients, and to update the recommendations and treatment algorithm proposed by the Brazilian Society of Rheumatology in 2017. IntroductionRheumatoid arthritis (RA) is a chronic and autoimmune systemic inflammatory disease characterized by involvement of the synovial membrane of peripheral joints. If not treated early and adequately, the disease can cause bone erosion and irreversible joint deformities, with increased morbidity and mortality and a significant impact on the quality of life of the affected individual [1]. RA affects up to 1% of the general population and is more common in women aged 40 to 60 years [2]. In the last 3 decades, there has been significant evolution in the management of patients with RA, with emphases on early diagnosis, rigorous monitoring of disease activity and goal-oriented treatment strategies. A better understanding of its pathophysiology has led to the development of new disease-modifying antirheumatic drugs (DMARDs), primarily biological DMARDs (bDMARDs) and, more recently, targeted synthetic DMARDs (tsDMARDs). The treatment objectives remain reducing joint and systemic inflammation with the aims of inhibiting disease progression, preventing loss of functionality and preserving patient quality of life [3,4,5]. Despite the various therapeutic options available, there are patients who do not achieve the desired response (remission or low disease activity) due to an inadequate clinical response (primary failure) or loss of response (secondary failure) or drug toxicity [6]. According to the most recent recommendations of the Brazilian Society of Rheumatology (SBR, for its initials in Portuguese) [1] and the European Alliance of Associations for Rheumatology (EULAR) [7], the main objective of RA treatment is to achieve sustained clinical remission or, in cases where this is not possible, low disease activity. However, up to 40% of patients do not respond to available treatments, including bDMARDs [1, 7]. New RA therapeutic targets are emerging. Janus kinases (JAKs), enzimes involved in intracellular signaling (JAK-STAT pathway), are essential to the control of response of many cytokines involved in the immunopathogenesis of RA. Therefore, JAK inhibitors (JAKis) have shown efficacy in the treatment of RA [8]. JAKis currently approved for commercialization in Brazil include tofacitinib [9] (JAK1 and JAK3 inhibitor), baricitinib [10] (JAK1 and JAK2 inhibitor) and upadacitinib [11] (selective JAK1 inhibitor). ObjectiveThe objective of these recommendations is to present a review, directed to rheumatologists, of the main aspects related to the efficacy and safety of JAKis in RA patients and to update the recommendations and treatment algorithm proposed by the SBR in 2017 [1]. MethodThis review followed a protocol developed by the members of the SBR Rheumatoid Arthritis Committee, who established questions based on real-life scenarios, that can be accessed in Additional files. For the purposes of these recommendations, the following acronym and nomenclature system was adopted: DMARDs:Disease-modifying antirheumatic drugs; csDMARDs:Conventional synthetic disease-modifying antirheumatic drugs—methotrexate (MTX), leflunomide (LEF), sulfasalazine (SSZ) and hydroxychloroquine (HCQ); tsDMARDs:Targeted synthetic disease-modifying antirheumatic drugs (JAK inhibitors)—baricitinib (BARI), tofacitinib (TOFA), upadacitinib (UPA), filgotinib (FILGO) and peficitinib (PEFI); bDMARDs:Biological disease-modifying antirheumatic drugs—tumor necrosis factor (TNFα-i) inhibitors adalimumab (ADA), certolizumab (CTZ), etanercept (ETA), golimumab (GOLI) and infliximab (IFX) and drugs with other mechanisms of non-TNFα-i action, i.e., abatacept (ABA), rituximab (RTX) and tocilizumab (TCZ); JAKi:Janus Kinase inhibitor mTSS:Modified total Sharp score; HAQ-DI:Health Assessment Questionnaire Disability Index; NSAIDs:Nonsteroidal antiinflammatory drugs; DAS28-CRP:Disease activity score 28/C-reactive protein. DAS28-ESR:Disease activity score 28/erythrocyte sedimentation rate. CDAI:Clinical Disease Activity Index. SDAI:Simplified Disease Activity Index. Remission:DAS28-CRP and/or DAS28-ESR < 2.6; and. Low disease activity:DAS28-CRP and/or DAS28-ESR ≥ 2.6 < 3.2. RCT:Randomized controlled trial. To answer the selected questions, systematic literature reviews (SLRs) were performed for each specific scenario. Elements of study eligibilityThe search for evidence was performed in virtual scientific information databases using search strategies specific to each question. The searches in these databases were performed until the month corresponding to the completion and submission of these guidelines for publication, and a systematic review was performed in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines [12]. The following data were extracted from the studies: name of the author and year of publication, population studied, methods of intervention and comparison, absolute number of events, and follow-up time. The risk of bias in randomized clinical trials was analyzed based on the following criteria: randomization, blinded allocation, double blinding, losses, prognostic characteristics, presence of expected outcome, time to outcome, outcome measurement method, sample calculation, early interruption, and presence of other biases. The measures used to express benefits and harms varied based on the outcomes and were expressed as continuous variables (mean and standard deviation) or categorical variables (absolute number of events). For continuous measures, the results reflect differences in means and standard deviation, and for categorical measures, the results reflect differences in risks and number needed to treat or produce harm, considering the number of patients. The confidence level was set at 95%. The results underwent meta-analysis when common outcomes among studies were observed. The results of the included studies were aggregated and meta-analyzed using RevMan 5.4 software [13]. In addition, the quality of the evidence was scored as high, moderate, low or very low using the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) instrument [14], taking into account the risk of bias, the presence of inconsistencies, imprecise or indirect evidence in the meta-analysis of outcomes and the presence of publication bias. The search strategies, selection process, characteristics and evaluation of the methodological quality of the included studies, as well as the synthesis of the results and quality of the evidence (based on GRADE), are available online as appendices. Elaboration of recommendationsThe process of drafting the recommendations relied on the participation of the SBR Rheumatoid Arthritis Committee, that included 27 rheumatologists from a panel of experts. Based on the SLR results for each clinical question as well as on the clinical experience of the experts, recommendations were elaborated and subjected to online voting. The first step involved agreeing about the structure and content of each of the propositions, requiring 70% agreement for inclusion of the proposition. When this value was not attained, the propositions were reformulated and submitted to a new voting stage until 70% agreement was met. Subsequently, the level of agreement was established based on the content in the propositions: the panel of experts assigned a degree of agreement using a numerical scale from 0 (“strongly disagree”) to 10 (“strongly agree”) for each recommendation. ResultsA summary of the search and synthesis of the evidence for each SLR performed is presented below, based on the proposed clinical questions. In all scenarios, adult patients (> 18 years old) who met the RA classification criteria of the American College of Rheumatology (ACR) of 1987 [15] or the 2010 ACR/EULAR criteria [16] were evaluated. All the details on the selection of studies, reasons for exclusion, list of excluded studies, and analysis of the quality of the evidence for the outcomes are available in the corresponding appendices of this publication. Efficacy and safety of tsDMARDs (JAKis) under different scenarios
A total of 403 studies were retrieved, individually accessed by title and/or abstract but only 3 were selected to support this evaluation. The reasons for exclusion and the list of excluded studies are available in the Additional file 1: Appendix 1 of this publication [17,18,19]. Evidence summary The following evidence pertains to adult patients with recent onset RA (symptoms < 6 months) or established RA (symptoms ≥ 6 months), regardless of disease activity, who received a nontherapeutic dose or no csDMARDs/bDMARDs. Results within 6 months
Results within 13 months
Safety
The search for evidence resulted in a total of 1658 articles. After reading the titles and abstracts, 1581 studies were excluded. The full texts of 77 studies were accessed, of which 19 [20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38] were selected to support this evaluation. (Additional file 2: Appendix 2). Evidence summary The following evidence pertains to patients with moderate or high RA activity after DMARD failure, followed by treatment with a JAKi.
Safety All JAKis, alone or in combination with MTX, showed acceptable safety compared to placebo for patients with moderate or high RA after failure of regimens with different csDMARDs, as determined by analyzing SAEs. The quality of evidence for this outcome ranged from moderate to very low. To better understand/define the safety of JAKis, more phase 4 studies are needed.
In the search for evidence, 58 studies were retrieved and individually assessed by title and/or abstract; 4 [39,40,41,42] references were selected for evaluation of their full texts. (Additional file 3: Appendix 3). Evidence summary The following evidence pertains to patients with a diagnosis of established RA who had an inadequate response to treatment with bDMARDs, followed by treatment with tsDMARDs (JAKis), either as a monotherapy or in combination with methotrexate or other csDMARDs, in comparison with placebo. Results within 3 months
Safety All JAKis, alone or in combination with MTX, after failure of bDMARDs, showed acceptable safety compared to placebo, as determined by analyzing SAEs. The quality of evidence supporting these results is high. Effectiveness, safety and cost of tsDMARDs (JAKis) in relation to csDMARDs and bDMARDs
In the search for evidence, 1325 studies were retrieved and individually assessed by title and/or abstract, from which 42 references were selected for evaluation of their full texts. Of the 42 studies, 4 [17, 19, 43, 44] randomized clinical trials were selected to support this evaluation, i.e., JAKis (TOFA, BARI and UPA) compared with MTX. A flow diagram is provided in the online supplementary Additional file 4: Appendix 4. Evidence summary The following evidence pertains to adult patients who met the RA classification criteria of the ACR or ACR/EULAR 2010 and in whom the the use of JAKis (TOFA, BARI and UPA) and csDMARDs (MTX) was compared. Results within 3–6 months
Results within 6–12 months
Safety
In the search for evidence, 1442 studies were retrieved and individually assessed by title and/or abstract, from which 33 references were selected for evaluation of their full texts. Of the 33 studies selected to support this evaluation, there were only 4 [45,46,47,48] randomized clinical trials that compared TOFA, BARI or UPA with ADA in combination with MTX. A flow diagram is provided in the Additional file 5: Appendix 5. Evidence summary The following evidence pertains to adult patients (> 16 years) with recent onset RA (symptoms < 6 months) and established RA (symptoms ≥ 6 months), regardless of disease activity, in whom the use of JAKis as a monotherapy or in combination with MTX was compared with the use of bDMARDs alone or combined with MTX. Results within 6 months
Results within 12 months
Safety
In the search for evidence, 203 studies were retrieved and individually assessed by title and/or abstract, from which 16 references were selected for full text evaluation. Of the 16 studies, only 2 were selected to support this evaluation [49, 50]. A flow diagram is provided in the online supplementary Additional file 6: Appendix 6. Evidence summary In patients with moderate to severe active RA, tsDMARDs (JAKis), compared with csDMARDs, were cost-effective in patients with inadequate responses to biological therapy. The literature, however, lacks studies that evaluate whether tsDMARDs are cost-effective when compared with csDMARDs after failure with another csDMARD. Future studies are needed to evaluate this scenario.
Studies were evaluated for risk of bias using the Critical Appraisal Skills Program—CASP (economic) evaluation checklist [1]. In the search for evidence, 203 studies were retrieved and individually assessed by title and/or abstract, of which 16 references were selected for full text evaluation. Of the 16 studies, only 6 were selected to support this evaluation [51,52,53,54,55,56,57]. Supporting material is available online in the supplementary Additional file 7: Appendix 7. Evidence summary
Evidence indicates that the use of JAKis is accompanied by a higher risk of infection by HZ [58, 59]. In the search for evidence, 1909 studies were retrieved and individually assessed by title and/or abstract, from which 19 references were selected for full text evaluation. Finally, in regard to the eligibility criteria, 4 studies were included [60,61,62,63]; the reasons for exclusion are found in the online supplementary Additional file 8: Appendix 8. Evidence summary
In the search for evidence, 1541 studies (RCT) were retrieved and individually assessed by title and/or abstract, from which 30 references were selected for full text evaluation. Of the 30 studies, 10 were selected to support this evaluation [64,65,66,67,68,69,70,71,72,73] (Fig. 1). The reasons for exclusion and the list of excluded studies, as well as the description of the included studies, are available in the Additional file 9: Appendix 9. Fig. 1 Updated flowchart of RA treatment in Brazil Full size image Evidence summary The following evidence pertains to adult patients with RA who used tsDMARDs (JAKis) as a monotherapy or in combination with MTX or other csDMARDs.
Safety of JAKi in light of recent warningsAlthough the present SLR has not shown unexpected findings regarding safety within each of the questions that guided the search, the authors considered necessary to discuss some recent data not covered in the SLR search period. On Oral Surveillance study [74], the prespecified non-inferiority criteria for the co-primary endpoints of major adverse cardiovascular events (MACE) and malignancies (excluding non-melanoma skin cancer), were not met for the primary comparison of the combined tofacitinib doses (5 mg twice daily and 10 mg twice daily) to TNF inhibitors (either etanercept 50 mg once weekly or adalimumab 40 mg every other week). However, despite this trial wrapping in July 2020,, its full results have been submitted but not yet published. Updates on this subject can be accessed at clinicaltrials.gov (https://clinicaltrials.gov/ct2/show/results/NCT02092467). In February 2021, a new “Food and Drug Administration” (FDA) warning regarding tofacitinib was issued [75]. FDA warned providers of an increased cardiovascular and cancer risk among older patients (> 50 years), compared with TNF-inhibitors. These warning has been based on interim and preliminary results from the ORAL Surveillance study [74]. In September 2021, FDA updated this previous warning, concluding that there is an increased risk of serious heart-related events such as heart attack or stroke, cancer, blood clots and death related with Tofacitinib. Based on that conclusion, required “Boxed warning” addings and revisions for all JAKi, including these findings and limiting all approved uses to certain patients who have not responded or cannot tolerate one or more TNF blockers [75]. European Medicines Agency (EMA) has also recommended an update to the product information for tofacitinib, and uttered a reminding to healthcare professionals to carefully evaluate a patient’s individual benefit-risk profile when deciding to prescribe or continue the treatment [76]. Considering clinical aspects of the patients included in the post-marketing trial, who presented not only advanced age, but also other risk factors for unfavorable outcomes, we suggest taking into account the risk–benefit ratio when considering prescription of JAKi. For patients already receiving JAKi, strict surveillance of those who meet the high-risk profile is recommended. Also taking into account the recent data, the SBR RA committee decided to re-vote recommendations 5 and 9 (see Table 1), and a warning note was included for JAKi prescription, as it follows: Table 1 General assumptions and recommendations of the SBR for the drug treatment of RA in Brazil Full size table Recommendation 5: After failure of 2 csDMARD regimens, a bDMARD or a tsDMARD can be used, preferably combined with a csDMARD. Note: Carefully consider the use of tsDMARD in populations at risk for major cardiovascular events, thromboembolic and neoplastic events, including patients over 50 (and especially those over 65) with traditional risk factors for disease cardiovascular (particularly current or past smokers). Recommendation 9: In case of failure of a bDMARD as initial treatment, a second bDMARD or a tsDMARD can be used. Note: Carefully consider the use of tsDMARD in risk groups for major cardiovascular events, thromboembolic and neoplastic events, including patients over 50 (and especially those over 65) with traditional risk factors for cardiovascular disease (particularly current or past smokers). Update of general assumptions and recommendations of the SBR committee on rheumatoid arthritisBased on the data previously presented and the voting process described, the RA Commission updated the therapeutic recommendations for RA in relation to the previous document [1]. Table 1 summarizes the general assumptions and recommendations of the SBR Rheumatoid Arthritis Committee for pharmacological treatment of RA in Brazil. The ones included in the present recommendations (5, 8, 9, 10 and 12) are highlighted in Table 1.
Flowchart for drug treatment of rheumatoid arthritisFigure 1 summarizes the updated flowchart for drug treatment of RA in Brazil proposed by the RA Commission of the SBR. ConclusionsImportant advances in the management of RA patients are leading a better patient prognosis. Rheumatologists, as specialist, are most familiar with the range of drugs available and their indications and adverse effects and are essential in the evaluation and treatment of patients diagnosed with RA. The appropriate allocation of healthcare resources, especially in a country of continental dimensions and with a growing population, such as Brazil, conducts to access to drugs and appropriate technologies for the treatment of various conditions. These recommendations took into account, in addition to issues of safety, efficacy and cost, the experience of specialists in the management of RA, considering specific characteristics of Brazil, such as the availability of drugs and the socioeconomic level of the population. Because the pace of knowledge acquisition in this field of science and the rise of new medications that are being analyzed for approval by Brazilian regulatory agencies, we recommend updating these guidelines every 2 years. Availability of data and materialsAll data generated or analyzed during this study are included in this published article, as “supplementary materials”. References
Download references AcknowledgementsThe authors wish to acknowledge the researcher Wanderley Bernardo, who is responsible for the systematic review—presented in detail in the supplementary material, funded by the Brazilian Society of Rheumatology. FundingBrazilian Society of Rheumatology. The funding body had no role in the design of the study and collection, analysis, and interpretation of data and in writing the manuscript. Author informationAuthors and Affiliations
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ContributionsAll authors made substantial contributions to the acquisition of data, have been involved in drafting the manuscript or revising it critically for important intellectual content, gave final approval of the version to be published and have participated sufficiently in the work to take public responsibility for appropriate portions of the content; and agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All authors read and approved the final manuscript. Corresponding authorCorrespondence to Karina Rossi Bonfiglioli. Ethics declarationsEthics approval and consent to participateNot applicable. Consent for publicationAll authors have read and approved the final version of this manuscript. Competing interestsKarina Rossi Bonfiglioli: Personal fees and/or non-financial support from Pfizer, Abbvie, Roche, Novartis, Boheringer-Ingelheim. Financial competing interest: none. Non-financial competing interest: none. Licia Maria Henrique da Mota: Has received personal or institutional support from Abbvie, Janssen, Pfizer and Roche; has delivered speeches at events related to this work and sponsored by Abbvie, Boheringer- Ingelheim, Janssen, Pfizer, Roche, Sandoz, Lilly and UCB. Financial competing interest: none. Non-financial competing interest: none. Ana Cristina de Medeiros Ribeiro: No conflicts declared. Adriana Maria Kakehasi: Research funds: CNPq, SBR, FAPEMIG Support for Scientific Events: Abbvie, BMS, Janssen Lecture Fees: UCB, Janssen, Pfizer, Roche, BMS Clinical research: Roche, Pfizer Advisory board: Janssen, Roche, BMS, Pfizer. Angela Luzia Branco Pinto Duarte: Lecture Fees: Janssen, BMS. Rina Dalva Neubarth Giorgi: Has received consulting fees,speaking fees and support for international congresses from: Roche,Pfizer,Bristol-Myers-Squibb, UCB Pharma, Eli-Lilly, AbbVie, Novartis, Amgen, Biogen and Janssen. Ieda Maria Magalhães Laurindo: Consultants for Abbvie,Amgen, Boehring-Ingelheim, Bristol, GSK, Janssen, Lilly, Pfizer and UCB; has received personal or institutional support from Abbvie, Bristol, Janssen, Lilly, Pfizer, UCB; has delivered speeches at events related to this work and sponsored by Abbvie, Bristol, Janssen, Lilly, Pfizer, Roche and UCB. Financial competing interest: none. Non-financial competing interest: none. Mariana Peixoto Guimarães Ubirajara e Silva de Souza: Suport for Research, Scientific Events, Lecture: UCB, Abbvie, BMS, Novartis, Pfizer, Amgen, Sandoz, Roche. Ana Paula Monteiro Gomides: Assistance for participation in events: Pfizer. Claiton Viegas Brenol: Has participated in clinical and/or experimental studies related to this work and sponsored by the PI (Abbvie, BMS, Janssen, Pfizer and Roche); has received personal or institutional support from the PI (Abbvie, BMS, Janssen, Pfizer and Roche); has delivered speeches at events related to this work and sponsored by the PI (Abbvie, Janssen, Pfizer and Roche). Financial competing interest: none. Non-financial competing interest: none. Geraldo da Rocha Castelar Pinheiro: No conflicts declared. Charlles Heldan de Moura Castro: No conflicts declared. Cleandro Pires de Albuquerque: Personal fees and/or non-financial support from Pfizer, Abbvie, AstraZeneca, Janssen, Bristol-Myers-Squibb, Roche, Novartis and UCB, outside the submitted article. Gustavo Luiz Behrens Pinto: Personal fees and/or non-financial support from Abbvie, Janssen, Roche and Novartis, outside the submitted article. Jose Fernando Verztman: personal fees and/or non-financial support from Pfizer, Abbvie, Roche, Novartis, Janssen, Lilly. Financial competing interest: none. Non-financial competing interest: none. Luciana Feitosa Muniz: No conflicts declared. Manoel Barros Bertolo: Has participated in clinical and/or experimental studies related to this work and sponsored by the PI (Roche); has delivered speeches at events related to this work and sponsored by the PI (Abbvie, Pfizer). Financial competing interest: none. Non-financial competing interest: none. Maria Raquel da Costa Pinto: Support in Congresses: UCB, Roche, Janssen, Bristol, Pfizer, Boheringer. Advisory Board: Janssen. Paulo Louzada Júnior: Sponsored by: Bristol-Myers Squibb, UCB, Pfizer Board Participation: Pfizer. Vitor Alves Cruz: Support in Congresses: UCB, Jansen, Abbvie and Pfizer. Ivanio Alves Pereira: Has received personal fee for lectures from Abbvie, Janssen, Pfizer and Roche; has delivered speeches at events related to this work and sponsored by Abbvie, Boheringer- Ingelheim, Janssen, Pfizer, Roche, Sandoz, Lilly and UCB. Financial competing interest: none. Non-financial competing interest: none. Max Vitor Carioca de Freitas: Speaker at events related to this work and sponsored by Abbvie, Novartis, Roche, Pfizer and UCB. Managing Partner of Integrare Therapeutics. Bóris Afonso Cruz: Support for Scientific Events and Lecture Fees: Abbvie, BMS, Janssen, Novartis, Pfizer, Roche. Eduardo Paiva: No conflicts declared. Odirlei Monticielo: Lectures and consultancies: Abbvie, APSEN, BMS, GSK, Janssen, Lilly, Novartis, Pfizer, Roche, UCB. José Roberto Provenza: No conflicts declared. Ricardo Machado Xavier: Lectures, consultancies: Abbvie, BMS, GSK, Janssen, Lilly, Novartis, Pfizer, Roche, UCB Clinical trials: Abbvie, UCB, Pfizer, GSK, Lilly. Additional informationPublisher's NoteSpringer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Supplementary InformationAdditional file 1.PICO 1 - Are tsDMARD (JAK inhibitors) effective and safe for the treatment ofRA patients in 1st line of treatment? (NOTE: "naive" or treatment-naive patients). Additional file 2.PICO 2 - Are tsDMARD (JAK inhibitors) effective and safe for the treatment ofRA patients after csdmard failure?. Additional file 3.PICO 3 - Are tsDMARD (JAK inhibitors) effective and safe for the treatment ofRA patients after bDMARD failure?. Additional file 4.PICO 4 - Are tsDMARD (JAK inhibitors) more effective for the treatment ofpatients with RA, compared to csDMARD?. Additional file 5.PICO 5 - Are tsDMARD (JAK inhibitors) more effective for the treatment ofpatients with RA compared to bDMARD?. Additional file 6.PICO 6 – Is there any evidence of better cost-effectiveness of tsDMARD (JAKinhibitors) compared to csDMARD?. Additional file 7.PICO 7 – Is there any evidence of better cost-effectiveness of tsDMARD (JAKinhibitors) compared to bDMARD?. Additional file 8.PICO 8 - Is there any evidence for herpes zoster vaccination eficcacybefore starting tsDMARD (JAK inhibitor) treatment?. Additional file 9.PICO 9 - Is there evidence of an increased risk of thromboembolic events related to treatment withMMCDsae (JAK inhibitors)?. Rights and permissionsOpen Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. Reprints and Permissions About this articleCite this articleBonfiglioli, K.R., da Mota, L.M.H., de Medeiros Ribeiro, A.C. et al. Recommendations of the Brazilian Society of Rheumatology for the use of JAK inhibitors in the management of rheumatoid arthritis. Adv Rheumatol 61, 70 (2021). https://doi.org/10.1186/s42358-021-00228-x Download citation
What are the primary objectives for treating RA?The aim of rheumatoid arthritis (RA) treatment is to control symptoms, prevent joint damage, and maximize your quality of life and ability to function.
What is the major goal when caring for a patient with rheumatic disease?Currently, the main goal in rheumatic research is to achieve remission, even in highly active stages of the disease.
What is the first line treatment for RA?Methotrexate. Methotrexate is now considered the first-line DMARD agent for most patients with RA.
What is the goal of arthritis treatment?Symptoms may include pain, stiffness, swelling, warmth, or redness in 1 or more joints. There is no cure for arthritis. The treatment goal is to limit pain and inflammation and preserve joint function. Treatment options include medicines, weight reduction, exercise, and surgery.
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