Cheryl Allen, BS Pharm, MBA: So, the ACR and the EULAR guidelines are similar in many respects. There are a couple of differentiators. One of the unique differentiators in the EULAR guidelines that was recently updated at the end of 2016 was the addressing of ways to prevent RA—ways to assist in helping with the symptomatology of UA—and that would be addressing obesity and smoking. The other thing that is similar between the 2 is going to be the treat-to-target. This is addressing the patient’s comorbid conditions as well as the expected side effects of medication in working between the rheumatologists and the patient to determine what that targeted outcome is. And then there’s agreement to treat to that target, hoping to get patients through that initial therapy—looking for 3 to 6 weeks before most patients see a response, up to about 3 months before we start seeing some of those broader effects, and the treatment for a full 6 months before we begin to look for additional agents.
As far as which guidelines should be followed, what we see more often in the United States is the ACR. Most folks are more familiar with those guidelines. However, if you look at the 2 together, the determinations on how we diagnose the disease is a collaboration between ACR and EULAR. When we look at the guidelines themselves, both start with methotrexate as the cornerstone of therapy and then seeing methotrexate through those first 3 months of therapy before there’s dose escalation. Many times for earlier arthritis, the dose escalation could be adding on a second or third DMARD, and they may be treating the flares with glucocorticoids.