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influential factors in physicians’ and patients’ decision-making when developing recommendations. In contrast to the 2015 guideline (1), recommendations were not provided for subgroups defined by early versus late RA disease duration. This change was made because current disease activity, prior therapies used, and the presence of comorbidities were felt to be more relevant than disease duration for most treatment decisions. However, early diagnosis and treatment in RA is associated with improved outcomes and is thus an important overarching principle in its management (12). Recommendations are intended for the general RA patient population and assume that patients do not have contraindications to the options under consideration. RESULTS/RECOMMENDATIONS The recommendations are based on a set of 81 PICO questions. The literature review initially identified 22,971 manuscripts (for the full set of PICO questions covering both pharmacologic and nonpharmacologic treatment). After excluding 18,333 titles Table 1. Guiding principles* RA requires early evaluation, diagnosis, and management. Treatment decisions should follow a shared decision-making process. Treatment decisions should be reevaluated within a minimum of 3 months based on efficacy and tolerability of the DMARD(s) chosen. Disease activity levels refer to those calculated using RA disease activity measures endorsed by the ACR (10). Recommendations are intended for the general RA patient population and assume that patients do not have contraindications to the options under consideration. Recommendations are limited to DMARDs approved by the US FDA for treatment of RA. csDMARDs: hydroxychloroquine, sulfasalazine, methotrexate, leflunomide bDMARDs: TNF inhibitors (etanercept, adalimumab, infliximab, golimumab, certolizumab pegol), T cell costimulatory inhibitor (abatacept), IL-6 receptor inhibitors (tocilizumab, sarilumab), anti-CD20 antibody (rituximab)† tsDMARDs: JAK inhibitors (tofacitinib, baricitinib, upadacitinib) Triple therapy refers to hydroxychloroquine, sulfasalazine, and either methotrexate or leflunomide. Serious infection refers to an infection requiring intravenous antibiotics or hospitalization. Biosimilars are considered equivalent to FDA-approved originator bDMARDs. Recommendations referring to bDMARDs exclude rituximab unless patients have had an inadequate response to TNF inhibitors (in order to be consistent with FDA approval) or have a history of lymphoproliferative disorder for which rituximab is an approved therapy. Treat-to-target refers to a systematic approach involving frequent monitoring of disease activity using validated instruments and modification of treatment to minimize disease activity with the goal of reaching a predefined target (low disease activity or remission). Target refers to low disease activity or remission. Recommendations specify that patients be at target (low disease activity or remission) for at least 6 months prior to tapering. Dose reduction refers to lowering the dose or increasing the dosing interval of a DMARD. Gradual discontinuation of a DMARD is defined as gradually lowering the dose of a DMARD and subsequently stopping it. * RA = rheumatoid arthritis; DMARDs = disease-modifying antirheumatic drugs; ACR = American College of Rheumatology; FDA = Food and Drug Administration; csDMARDs = conventional DMARDs; bDMARDs = biologic DMARDs; TNF = tumor necrosis factor; IL-6 = interleukin-6; tsDMARDs = targeted synthetic DMARDs. † Anakinra was not included due to infrequent use for patients with RA. ACR GUIDELINE FOR TREATMENT OF RA | 927 and abstracts, 4,038 full-text articles were screened, of which 1,392 were excluded and 2,646 were considered for the evidence report. After full-text screening, 133 manuscripts were
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