Recommendations of the French Society for Rheumatology regarding TNFα antagonist therapy in patients with rheumatoid arthritis

Objectives: To update French Society for Rheumatology guidelines regarding the use of TNF alpha antagonists for treating patients with rheumatoid arthritis (RA). Methods: Existing guidelines were updated using the AGREE instrument. Items that required updating were selected by a task force, the relevant literature was critically appraised, and new wording was suggested by a limited committee of experts then validated by the task force and subsequently by a panel of external reviewers. The three-topic structure of the recommendations (indication, initiation, and adjustment) and the final algorithm format were maintained. Results: Of the 12 items, five were selected for updating; one pertained to the indication for treatment with TNF alpha antagonists, two to treatment initiation, and two to treatment adjustment. Of the four initially recommended criteria for determining that TNF alpha antagonist therapy is indicated, the first three were left unchanged (confirmed diagnosis of RA; active disease for more than 1 month with objective evidence of inflammation or progressive structural damage, or dependency on glucocorticoid therapy, or progressive radiographic damage; and failure to respond adequately to methotrexate - or another agent when methotrexate is contraindicated - in the optimal tolerated dosage). The fourth and last criterion was modified as follows: co-morbidities should be evaluated in order to distinguish absolute contraindications from relative contraindications that require referral to a specialist. Of the four initial recommendations about TNF alpha antagonist initiation, the first and fourth were left unchanged (a workup should be performed prior to treatment initiation, and the patient should receive regular standardized follow-up); the second and third recommendations were modified as follows: there is no evidence that one TNF alpha antagonist is more effective than the others, and concomitant methotrexate therapy is generally advisable, regardless of the TNF alpha antagonist used. Of the four recommendations about treatment adjustment, the first two were modified as follows: the goal of treatment is to achieve the EULAR response criteria or better; and in non-responders, the dosage or dosing interval can be modified when infliximab is used, methotrexate should be added when the TNF alpha antagonist is used alone, and in all other situations the patient should be switched to a different TNF alpha antagonist. The other two recommendations about treatment adjustment were left unchanged (patients who fail to tolerate one TNF alpha antagonist can be switched to another TNF alpha antagonist if allowed by the nature of the adverse event; and when a remission is achieved, reduction or discontinuation of symptomatic drugs - most notably glucocorticoids - is appropriate, followed in the event of a prolonged remission by changes in the dosage and/or dosing interval of the TNF alpha antagonist or concomitant disease-modifying drug). Conclusion: These recommendations are designed to help practitioners optimize the use of TNF alpha. antagonists in patients with RA seen in everyday practice. They do not constitute regulations. (C) 2007 Elsevier Masson SAS. All rights reserved.