Aktualisiertes Therapieschema der Rheumatoiden Arthritis. Ergebnisse eines Konsensusprozesses deutscher Rheumatologen 2009

The aim of treatment for newly diagnosed rheumatoid arthritis (RA) is to achieve a complete remission, which means not only a reduction of disease activity (DAS28) below 2.6, but also the absence of clinically silent synovitis and/or radiographic progression as shown by negative ultrasound or MRI. We report the results of a consensus process towards an update of the practical recommendations for the treatment of rheumatoid arthritis. Methotrexate remains the anchor drug and should be used as monotherapy or in a DMARD combination, for example, with Leflunomide. Partial responders should then receive one of the available TNF antagonists, i. e., adalimumab, etanercept or infliximab. In the near future, further TNF antibodies (golimumab and certolizumab-pegol) will become available. For patients exhibiting an inadequate response to a TNF blocker, four options are available: the use of a second TNF antagonist (especially in patients with a loss of the initial response), or a switch to one of three other modes of action: the anti-interleukin-6-antagonist tozilizumab, the anti-CD20 B-cell inhibitor rituximab, or the inhibitor of T-cell costimulation abatacept, respectively. Individual factors are taken into consideration to help to decide upon a treatment escalation. In patients with long-standing remission, a step-down approach should be considered.