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recommendation. Future studies (using large registries and network meta-analyses) are needed to support specific recommendations for this patient population. The recommendation statements in this update are not directly comparable to the ACR 2015 guidelines (1) because they do not retain the early versus established RA subgroups. Nevertheless, there are some notable differences. First, the 2015 guidelines recommend csDMARD monotherapy, preferably with methotrexate, for patients with both low and moderate/high disease activity, whereas this update recommends an initial trial of hydroxychloroquine or sulfasalazine for those with low disease activity. Second, the 2015 guidelines recommended DMARD tapering for patients who are in remission. In this update, tapering recommendations are made for patients who are in low disease activity or remission in the face of a paucity of data about when and how best to taper. The panel recommended that careful tapering might be considered if the patient wishes to cut back on their use of DMARDs. However, patients should be closely evaluated during any taper, and if a flare occurs, the prior regimen should be reinstituted promptly. Last, this update includes several recommendations against the use of glucocorticoid therapy. These recommendations were made in recognition of the frequent difficulty tapering glucocorticoids leading to undesirable prolonged use and the increasing evidence of the negative impact of glucocorticoids on long-term patient outcomes, including risk for infection, osteoporosis, and cardiovascular disease, in RA and other rheumatic diseases (62–65). While consensus was easily reached on the majority of statements, 2 issues required prolonged discussion and debate. The decision on whether patients with an inadequate response to methotrexate should escalate to a bDMARD, tsDMARD, or triple therapy engendered much discussion with contrasting points of view. In the end, a recommendation was made in favor of a bDMARD or tsDMARD because of the more rapid onset of benefit and concerns related to the poor tolerability and durability of triple therapy in real-world practice (13,14). In particular, the patient panel highlighted the importance of a rapid onset of benefit after already having had an inadequate response to methotrexate. The conditional recommendation to initiate methotrexate therapy for patients with preexisting mild, stable lung disease was also rigorously debated. While minimizing the risk of toxicity is paramount, the voting panel favored a conditional recommendation to initiate methotrexate therapy in this clinical setting because of the vital role of this DMARD in the overall treatment of RA and lack of other comparable therapies without pulmonary risks. Members of the voting panel agreed with the patient panel on the direction and strength of all but 2 recommendations. Patients were in favor of initial treatment with combination csDMARDs over methotrexate monotherapy because they placed greater value on the incremental benefits associated with combination therapy compared to clinicians. This preference was also stated in the 2015 guidelines (66). Patients also strongly preferred ACR GUIDELINE FOR TREATMENT OF RA | 937 discontinuing over a dose reduction of a DMARD whenever possible, whereas most clinicians on the voting panel preferred dose reduction. This discordance reflects patient preference to minimize use of medications once they reach target versus physician preference to minimize flare. However, both the patient and voting panel stressed the variability in patient preferences for tapering. These differences reinforce the importance of using a shared decision-making approach in RA. When clinically relevant,
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