The updated EULAR recommendations published in "The Annals of the Rheumatic Diseases" offered consensus on rheumatoid arthritis management encompassing effectiveness, cost, and safety. This study aimed to offer an update on the management guidelines for rheumatoid arthritis that takes into account the most recent scientific advancements. A global task group was established, and 3 systematic literature reviews on the effectiveness and safety of disease-modifying antirheumatic drugs (DMARDs) and glucocorticoids were requested. With reference to the most recent update from 2019, the newest evidence was discussed. Each guiding concept and recommendation was put to a vote according to a predetermined process.

Participants offered each item a level of evidence and strength of recommendation before voting on how strongly they agreed with it. Five overarching principles and 11 suggestions were adopted by the task force regarding the usage of glucocorticoids; conventional synthetic (cs) DMARDs (sulfasalazine, leflunomide, methotrexate); targeted synthetic (ts) DMARDs, such as the Janus kinase inhibitors baricitinib, filgotinib, upadacitinib, and tofacitinib, and biological (b) DMARDs (tumor necrosis factor inhibitors [golimumab, etanercept, adalimumab, certolizumab pegol, infliximab including biosimilars], rituximab, abatacept, tocilizumab, sarilumab.

Advice was given on monotherapy, combination therapy, treatment plans (treat-to-target), and tapering in long-term clinical remission. Costs and the sequencing of b/ts DMARDs were taken into consideration, along with safety factors such as the risk of major cardiovascular events (MACEs) and cancer. Methotrexate + glucocorticoids are advised initially, and if this therapy does not produce sufficient results within 3–6 months, treatment must be based on stratification as per the risk variables.

Any bDMARD must be added to the csDMARD when there are poor prognostic indicators (autoantibodies, elevated activity of disease, early erosions or failure of 2 csDMARDs). tsDMARDs might also be contemplated in this phase following a thorough assessment of the risks of MACEs,  thromboembolic events, and malignancies. Any additional bDMARD (from another or the same class) or tsDMARD (regarding hazards) is advised if the first bDMARD (or tsDMARD) fails. DMARDs may be reduced but should not be withdrawn in cases of persistent remission. For the majority of recommendations, the levels of agreement and evidence were elevated.