Clinical practice format for choosing a second-line disease modifying anti-rheumatic drug in early rheumatoid arthritis after failure of 6 months' first-line DMARD therapy

Joint Bone Spine. 2007 Jan;74(1):73-8. doi: 10.1016/j.jbspin.2006.05.008. Epub 2006 Nov 29.


Background: The objective was to develop a clinical practice format for choosing a second-line disease-modifying anti-rheumatic drug (DMARD) after a 6-month course of a first-line DMARD in patients with early RA.

Methods: A panel of 34 experts selected treatment option from various scenarios using the Thurstone pairwise method. The experts had to choose between two proposed DMARDs without proposing other options. The scenarios were obtained using the three items: DAS28, rheumatoid factor status and radiographic structural damage. A sample of 240 among 480 scenarios for each expert was taken at random. Responses given by at least 20% of the experts were considered pertinent.

Results: Recommendations for choosing a second DMARD for early RA after failure of a 6-month course of a first-line DMARD were established according to 4 parameters: type of first-line DMARD, activity, RF status and radiographic joint damage. The results of this study suggest that in patients with early RA who fail a 6-month course of first-line DMARD therapy, the best options may be addition of corticosteroid when disease activity is moderate to high and switching to a biologic agent when further radiographic joint damage occurs, particularly in patients with positive tests for RF.

Conclusion: Although our scenarios did not include step-up (add instead of substitute) strategies, except for corticosteroids, we feel that the format presented here can optimise the management of patients with early RA seen in clinical practice.

Publication types

  • Consensus Development Conference
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Antirheumatic Agents / therapeutic use*
  • Arthritis, Rheumatoid / diagnostic imaging
  • Arthritis, Rheumatoid / drug therapy*
  • Arthritis, Rheumatoid / metabolism
  • Biomarkers / metabolism
  • Decision Support Techniques
  • Drug Administration Schedule
  • Drug Therapy, Combination
  • Etanercept
  • Humans
  • Immunoglobulin G / therapeutic use
  • Isoxazoles / therapeutic use
  • Leflunomide
  • Methotrexate / therapeutic use
  • Practice Guidelines as Topic*
  • Radiography
  • Receptors, Tumor Necrosis Factor / therapeutic use
  • Rheumatoid Factor / metabolism
  • Sulfasalazine / therapeutic use
  • Treatment Failure


  • Antirheumatic Agents
  • Biomarkers
  • Immunoglobulin G
  • Isoxazoles
  • Receptors, Tumor Necrosis Factor
  • Sulfasalazine
  • Rheumatoid Factor
  • Leflunomide
  • Etanercept
  • Methotrexate