The "dirty little secret" exposed in the 2013 EULAR recommendations for rheumatoid arthritis therapy.

The European League Against Rheumatism (EULAR) recently updated its recommendations on the management of rheumatoid arthritis (RA) with synthetic and disease-modifying antirheumatic drugs (DMARDs), motivated by the availability of new treatment options over the past 3 or 4 years. Modifications since 2010 include the removal of the recommendation of the use of azathioprine, cyclosporine A, or cyclophosphamide for the treatment of RA. Furthermore, there is no longer an expressed preference for tumor necrosis factor inhibitors, including the approved biosimilar tumor necrosis factor inhibitors, over abatacept (a co-stimulatory blocker), tocilizumab (an interleukin-6 inhibitor), or rituximab (a B-cell antibody) when conventional DMARDs are not sufficiently effective. However, the use of tofacitinib (a Janus-associated kinase inhibitor) should come after initial biologic treatment has failed, due to uncertainty about the long-term safety and cost considerations of tofacitinib in comparison to biologic DMARDs. It was recommended that DMARD-naive patients be treated with either conventional DMARD monotherapy or DMARD combination therapy up front, and that low-dose glucocorticoids "should be considered" as a part of the initial treatment strategy, with glucocorticoids tapered within 6 months. Because glucocorticoids have been reported to retard joint damage and have been associated with negligible adverse events at low doses, perhaps the 2013 EULAR recommendation did not go far enough in its support of low-dose glucocorticoid use. Almost 60 years have passed since the initial discovery of glucocorticoid efficacy in the treatment of RA, and despite the flurry of new and exciting medications for the treatment of RA, we still have not come to a consensus on how the first effective, and now the least expensive, RA therapy should be used.