2023 Management Recommendations of Bangladesh Rheumatology Society on Pharmacological Treatment of Rheumatoid Arthritis With Synthetic and Biologic Disease-Modifying Drugs

Abstract

Rheumatoid arthritis (RA) is the most common inflammatory polyarthritis in Bangladesh. Bangladesh Rheumatology Society (BRS) proposes these management recommendations to treat the considerable burden of RA in the resource-constrained situation based on the best current evidence combined with societal challenges and opportunities. BRS formed a task force (TF) comprising four rheumatologists. The TF searched for all available literature, including updated American College of Rheumatology (ACR), European Alliance of Associations for Rheumatology (EULAR), and Asia-Pacific League of Associations for Rheumatology (APLAR) and several other guidelines, and systematic literature reviews until October 2023, and then a steering committee was formed, which included rheumatologists and internists. We followed the EULAR standard operating procedures to categorize levels of evidence and grading of recommendations. This recommendation has two parts -- general (diagnosis of RA, nomenclature of disease-modifying anti-rheumatic drugs [DMARDs], disease activity indices) and management portion. The TF agreed on four overarching principles and 12 recommendations. Overarching principles deal with early diagnosis and disease activity monitoring. Recommendations 1-5 discuss using glucocorticoids, NSAIDs, and conventional synthetic DMARDs (csDMARD). Recommendations 6-9 stretch the use of targeted synthetic DMARDs (tsDMARDs) and biological DMARDs (bDMARDs). The suggested DMARD therapy includes initiation with methotrexate (MTX) or another csDMARD (in case of contraindication to MTX) in the first phase and the addition of a tsDMARD in the second phase, switching to an alternative tsDMARDs or bDMARDs in the subsequent phases. The TF included the Padua prediction score for the thromboembolism risk estimation. Recommendations 10-12 cover infection screening, vaccination, and DMARD tapering. Bangladesh has a higher prevalence of RA. This recommendation will serve as a tool to treat this high burden of patients with RA scientifically and more effectively.

Keywords: bangladesh rheumatology society; disease-modifying drugs; management recommendation; pharmacologic treatment; rheumatoid arthritis.

Figure 1. Flowchart for RA management

Use 2010 ACR/EULAR RA criteria to diagnose RA. The different color schemes in the algorithm represent consecutive stages of RA management. The color brown represents the first stage of managing rheumatoid arthritis (RA), while the color green denotes the second stage when the initial treatment with MTX (or other csDMARD) fails. The color pink is used to depict the third stage of therapy for patients who do not respond well to the second stage. csDMARD, conventional synthetic DMARD; JAK inhibitor, Janus kinase inhibitor; bDMARD, biological disease-modifying drugs. Image credit: Muhammad Shaoib Momen Majumder.

Figure 2. Approach for LTBI

CECT, contrast-enhanced computed tomography; TST, tuberculin skin test; QFTG, QuantiFERON-TB Gold plus assay; Healed TB, only calcification or fibrotic lesions (fibrotic linear opacity, reticular fibrotic scars) in the absence of radiological evidence of active TB (upper lobe consolidation, unilateral hilar lymphadenopathy, cavitary lesions). Image credit: Muhammad Shoaib Momen Majumder.