Turkish League Against Rheumatism (TLAR) Recommendations for the Pharmacological Management of Rheumatoid Arthritis: 2018 Update Under Guidance of Current Recommendations

Öz:

Objectives: This study aims to report the assessment of the Turkish League Against Rheumatism (TLAR) expert panel on the compliance and adaptation of the European League Against Rheumatism (EULAR) 2016 recommendations for the management of rheumatoid arthritis (RA) in Turkey. Patients and methods: The EULAR 2016 recommendations for the treatment of RA were voted by 27 specialists experienced in this field with regard to participation rate for each recommendation and significance of items. Afterwards, each recommendation was brought forward for discussion and any alteration gaining ≥70% approval was accepted. Also, Turkish version of each item was rearranged. Last version of the recommendations was then revoted to determine the level of agreement. Levels of agreement of the two voting rounds were compared with Wilcoxon signed-rank test. In case of significant difference, the item with higher level of agreement was accepted. In case of no difference, the changed item was selected.Results: Four overarching principles and 12 recommendations were assessed among which three overarching principles and one recommendation were changed. The changed overarching principles emphasized the importance of physical medicine and rehabilitation specialists as well as rheumatologists for the care of RA patients in Turkey. An alteration was made in the eighth recommendation on treatment of active RA patients with unfavorable prognostic indicators after failure of three conventional disease modifying anti-rheumatic drugs. Remaining principles were accepted as the same although some alterations were suggested but could not find adequate support to reach significance. Conclusion: Expert opinion of the TLAR for the treatment of RA was composed for practices in Turkish rheumatology and/or physical medicine and rehabilitation clinics.

Anahtar Kelime:

Konular: Romatoloji

Belge Türü: Makale Makale Türü: Araştırma Makalesi Erişim Türü: Erişime Açık

Cohen G, Gossec L, Dougados M, Cantagrel A, Goupille P, Daures JP, et al. Radiological damage in patients with rheumatoid arthritis on sustained remission. Ann Rheum Dis 2007;66:358-63.
Brown AK, Quinn MA, Karim Z, Conaghan PG, Peterfy CG, Hensor E, et al. Presence of significant synovitis in rheumatoid arthritis patients with disease-modifying antirheumatic drug-induced clinical remission: evidence from an imaging study may explain structural progression. Arthritis Rheum 2006;54:3761-73.
O’Mahony R, Richards A, Deighton C, Scott D. Withdrawal of disease-modifying antirheumatic drugs in patients with rheumatoid arthritis: A systematic review and meta-analysis. Ann Rheum Dis 2010;69:1823-6.
van der Woude D, Young A, Jayakumar K, Mertens BJ, Toes RE, van der Heijde D, et al. Prevalence of and predictive factors for sustained disease-modifying antirheumatic drug-free remission in rheumatoid arthritis: Results from two large early arthritis cohorts. Arthritis Rheum 2009;60:2262-71.
Scott IC, Kingsley GH, Scott DL. Can we discontinue synthetic disease-modifying anti-rheumatic drugs in rheumatoid arthritis? Clin Exp Rheumatol 2013;31(4 Suppl 78):S4-8.
Naredo E, Valor L, De la Torre I, Montoro M, Bello N, Martinez-Barrio J, et al. Predictive value of doppler ultrasound-detected synovitis in relation to failed tapering of biologic therapy in patients with rheumatoid arthritis. Rheumatology (Oxford) 2015;54:1408-14.
Schett G, Emery P, Tanaka Y, Burmester G, Pisetsky DS, Naredo E, et al. Tapering biologic and conventional dmard therapy in rheumatoid arthritis: Current evidence and future directions. Ann Rheum Dis 2016;75:1428-37.
Lau CS, Gibofsky A, Damjanov N, Lula S, Marshall L, Jones H, et al. Down-titration of biologics for the treatment of rheumatoid arthritis: a systematic literature review. Rheumatol Int 2017;37:1789-98.
Henaux S, Ruyssen-Witrand A, Cantagrel A, Barnetche T, Fautrel B, Filippi N, et al. Risk of losing remission, low disease activity or radiographic progression in case of bDMARD discontinuation or tapering in rheumatoid arthritis: systematic analysis of the literature and meta-analysis. Ann Rheum Dis 2018;77:515-22.
Yasuda S, Ohmura K, Kanazawa H, Kurita T, Kon Y, Ishii T, et al. Maintenance treatment using abatacept with dose reduction after achievement of low disease activity in patients with rheumatoid arthritis (matador) - a prospective, multicenter, single arm pilot clinical trial. Mod Rheumatol 2017;27:930-7.
Smolen JS, Nash P, Durez P, Hall S, Ilivanova E, Irazoque-Palazuelos F, et al. Maintenance, reduction, or withdrawal of etanercept after treatment with etanercept and methotrexate in patients with moderate rheumatoid arthritis (PRESERVE): a randomised controlled trial. Lancet 2013;381:918-29.
Emery P, Hammoudeh M, FitzGerald O, Combe B, Martin-Mola E, Buch MH, et al. Sustained remission with etanercept tapering in early rheumatoid arthritis. N Engl J Med 2014;371:1781-92.
Hamann P, Holland R, Hyrich K, Pauling JD, Shaddick G, Nightingale A, et al. Factors associated with sustained remission in rheumatoid arthritis in patients treated with anti-tumor necrosis factor. Arthritis Care Res (Hoboken) 2017;69:783-93.
Ruiz-Argüello MB, Maguregui A, Ruiz Del Agua A, Pascual-Salcedo D, Martínez-Feito A, Jurado T, et al. Antibodies to infliximab in Remicade-treated rheumatic patients show identical reactivity towards biosimilars. Ann Rheum Dis 2016;75:1693-6.
Brodszky V, Baji P, Balogh O, Péntek M. Budget impact analysis of biosimilar infliximab (CT-P13) for the treatment of rheumatoid arthritis in six Central and Eastern European countries. Eur J Health Econ 2014;15 Suppl 1:S65-71.
Jamshidi A, Gharibdoost F, Vojdanian M, Soroosh SG, Soroush M, Ahmadzadeh A, et al. A phase III, randomized, two-armed, double-blind, parallel, active controlled, and non-inferiority clinical trial to compare efficacy and safety of biosimilar adalimumab (CinnoRA®) to the reference product (Humira®) in patients with active rheumatoid arthritis. Arthritis Res Ther 2017;19:168.
Smolen JS, Cohen SB, Tony HP, Scheinberg M, Kivitz A, Balanescu A, et al. A randomised, double-blind trial to demonstrate bioequivalence of gp2013 and reference rituximab combined with methotrexate in patients with active rheumatoid arthritis. Ann Rheum Dis 2017;76:1598-602.
Yoo DH, Racewicz A, Brzezicki J, Yatsyshyn R, Arteaga ET, Baranauskaite A, et al. A phase III randomized study to evaluate the efficacy and safety of CT-P13 compared with reference infliximab in patients with active rheumatoid arthritis: 54-week results from the PLANETRA study. Arthritis Res Ther 2016;18:82.
Wei W, Knapp K, Wang L, Chen CI, Craig GL, Ferguson K, et al. Treatment persistence and clinical outcomes of tumor necrosis factor ınhibitor cycling or switching to a new mechanism of action therapy: real-world observational study of rheumatoid arthritis patients in the united states with prior tumor necrosis factor ınhibitor therapy. Adv Ther 2017;34:1936-52.
Rheumatoid arthritis in adults: Management, clinical guideline. National institute for health and care excellence. Adalimumab, etanercept, infliximab, rituximab and abatacept for the treatment of rheumatoid arthritis after the failure of a TNF inhibitor. Technology Appraisal Guidance [TA195] [Published date: August 25, 2010]. Available from: https://www.nice.org.uk/guidance/ta195/chapter/1Guidance [Access date: February 10, 2018]
Bessette L, Khraishi M, Kivitz AJ, Kaliyaperumal A, Grantab R, Poulin-Costello M, et al. Single-arm study of etanercept in adult patients with moderate to severe rheumatoid arthritis who failed adalimumab treatment. Rheumatol Ther 2017;4:391-404.
Gottenberg JE, Brocq O, Perdriger A, Lassoued S, Berthelot JM, Wendling D, et al. Non-TNFtargeted biologic vs a second anti-TNF drug to treat rheumatoid arthritis in patients with insufficient response to a first anti-TNF drug: A Randomized Clinical Trial. JAMA 2016;316:1172-80.
NICE. Adalimumab, etanercept, infliximab, certolizumab pegol, golimumab, tocilizumab and abatacept for rheumatoid arthritis not previously treated with DMARDs or after conventional DMARDs only have failed. London (UK): National Institute for Health and Care Excellence (NICE). Technology Appraisal Guidance; No. 375. 2016. Available from: https://www.nice.org.uk/guidance/ta375. [Access date: February 10, 2018]
Gaubitz M, Göttl KH, Behmer O, Lippe R, Meng T, Löschmann PA. Etanercept is effective as monotherapy or in combination with methotrexate in rheumatoid arthritis: subanalysis of an observational study. Clin Rheumatol. 2017;36:1989-96.
Tarp S, Furst DE, Dossing A, Ostergaard M, Lorenzen T, Hansen MS, et al. Defining the optimal biological monotherapy in rheumatoid arthritis: A systematic review and meta-analysis of randomised trials. Semin Arthritis Rheum 2017;46:699-708.
van Riel PL, Taggart AJ, Sany J, Gaubitz M, Nab HW, Pedersen R, et al. Efficacy and safety of combination etanercept and methotrexate versus etanercept alone in patients with rheumatoid arthritis with an inadequate response to methotrexate: the ADORE study. Ann Rheum Dis 2006;65:1478-83.
Claxton L, Jenks M, Taylor M, Wallenstein G, Mendelsohn AM, Bourret JA, et al. An economic evaluation of tofacitinib treatment in rheumatoid arthritis: modeling the cost of treatment strategies in the United States. J Manag Care Spec Pharm 2016;22:1088-102.
Fleischmann R, Mysler E, Hall S, Kivitz AJ, Moots RJ, Luo Z, et al. Efficacy and safety of tofacitinib monotherapy, tofacitinib with methotrexate, and adalimumab with methotrexate in patients with rheumatoid arthritis (ORAL Strategy): a phase 3b/4, double-blind, head-to-head, randomised controlled trial. Lancet 2017;390:457-68.
Fleischmann RM, Huizinga TW, Kavanaugh AF, Wilkinson B, Kwok K, DeMasi R, et al. Efficacy of tofacitinib monotherapy in methotrexate-naive patients with early or established rheumatoid arthritis. RMD Open 2016;2:e000262.
Fleischmann R, Kremer J, Cush J, Schulze-Koops H, Connell CA, Bradley JD, et al. Placebo-controlled trial of tofacitinib monotherapy in rheumatoid arthritis. N Engl J Med 2012;367:495-507.
Dougados M, Kissel K, Conaghan PG, Mola EM, Schett G, Gerli R, et al. Clinical, radiographic and immunogenic effects after 1 year of tocilizumabbased treatment strategies in rheumatoid arthritis: the ACT-RAY study. Ann Rheum Dis 2014;73:803-9.
Burmester GR, Rigby WF, van Vollenhoven RF, Kay J, Rubbert-Roth A, Blanco R, et al. Tocilizumab combination therapy or monotherapy or methotrexate monotherapy in methotrexatenaive patients with early rheumatoid arthritis: 2-year clinical and radiographic results from the randomised, placebo-controlled FUNCTION trial. Ann Rheum Dis 2017;76:1279-84.
Jones G, Wallace T, McIntosh MJ, Brockwell L, Gómez-Reino JJ, Sebba A. Five-year efficacy and safety of tocilizumab monotherapy in patients with rheumatoid arthritis who were methotrexate- and biologic-naive or free of methotrexate for 6 months: the AMBITION Study. J Rheumatol 2017;44:142-6.
Jalal H, O’Dell JR, Bridges SL Jr, Cofield S, Curtis JR, Mikuls TR, et al. Cost-Effectiveness of triple therapy versus etanercept plus methotrexate in early aggressive rheumatoid arthritis. Arthritis Care Res (Hoboken) 2016;68:1751-7.
Kavanaugh A, van Vollenhoven RF, Fleischmann R, Emery P, Sainsbury I, Florentinus S, et al. Testing treat-to-target outcomes with initial methotrexate monotherapy compared with initial tumour necrosis factor inhibitor (adalimumab) plus methotrexate in early rheumatoid arthritis. Ann Rheum Dis 2018;77:289-92.
Atsumi T, Yamamoto K, Takeuchi T, Yamanaka H, Ishiguro N, Tanaka Y, et al. The first doubleblind, randomised, parallel-group certolizumab pegol study in methotrexate-naive early rheumatoid arthritis patients with poor prognostic factors, C-OPERA,shows inhibition of radiographic progression. Ann Rheum Dis 2016;75:75-83
Bijlsma JWJ, Welsing PMJ, Woodworth TG, Middelink LM, Pethö-Schramm A, Bernasconi C, et al. Early rheumatoid arthritis treated with tocilizumab, methotrexate, or their combination (U-Act-Early): a multicentre, randomised, double-blind, doubledummy, strategy trial. Lancet 2016;388:343-55.
Detert J, Bastian H, Listing J, Weiß A, Wassenberg S, Liebhaber A, et al. Induction therapy with adalimumab plus methotrexate for 24 weeks followed by methotrexate monotherapy up to week 48 versus methotrexate therapy alone for DMARDnaive patients with early rheumatoid arthritis: HIT HARD, an investigator-initiated study. Ann Rheum Dis 2013;72:844-50.
van der Kooij SM, le Cessie S, Goekoop-Ruiterman YP, de Vries-Bouwstra JK, van Zeben D, Kerstens PJ, et al. Clinical and radiological efficacy of initial vs delayed treatment with infliximab plus methotrexate in patients with early rheumatoid arthritis. Ann Rheum Dis 2009;68:1153-8.
Bejarano V, Conaghan PG, Quinn MA, Saleem B, Emery P. Benefits 8 years after a remission induction regime with an infliximab and methotrexate combination in early rheumatoid arthritis. Rheumatology (Oxford) 2010;49:1971-4.
Tanaka Y, Hirata S, Saleem B, Emery P. Discontinuation of biologics in patients with rheumatoid arthritis. Clin Exp Rheumatol 2013;31(4 Suppl 78):S22-7.
Wijesinghe H, Galappatthy P, de Silva R, Seneviratne SL, Saravanamuttu U, Udagama P, et al. Leflunomide is equally efficacious and safe compared to low dose rituximab in refractory rheumatoid arthritis given in combination with methotrexate: results from a randomized double blind controlled clinical trial. BMC Musculoskelet Disord 2017;18:310.
Porter D, van Melckebeke J, Dale J, Messow CM, McConnachie A, Walker A, et al. Tumour necrosis factor inhibition versus rituximab for patients with rheumatoid arthritis who require biological treatment (ORBIT): an open-label, randomised controlled, noninferiority, trial. Lancet 2016;388:239-47.
Taylor PC, Keystone EC, van der Heijde D, Weinblatt ME, Del Carmen Morales L, Reyes Gonzaga J, et al. Baricitinib versus placebo or adalimumab in rheumatoid arthritis. N Engl J Med 2017;376:652-62.
Rheumatoid arthritis in adults: Management, clinical guideline. National institute for health and care excellence. Tofacitinib for moderate to severe rheumatoid arthritis. Technology appraisal guidance [TA480] Published date: 11 October 2017. Available from: https://www.nice.org.uk/guidance/ ta480/chapter/1-Recommendations. [Access date: February 10, 2018]
Charles-Schoeman C, Burmester G, Nash P, Zerbini CA, Soma K, Kwok K, et al. Efficacy and safety of tofacitinib following inadequate response to conventional synthetic or biological disease-modifying antirheumatic drugs. Ann Rheum Dis 2016;75:1293-301.
Bergrath E, Gerber RA, Gruben D, Lukic T, Makin C, Wallenstein G. Tofacitinib versus biologic treatments in moderate-to-severe rheumatoid arthritis patients who have had an ınadequate response to nonbiologic DMARDs: systematic literature review and network meta-analysis. Int J Rheumatol 2017;2017:8417249.
Westhovens R, Kremer JM, Emery P, Russell AS, Alten R, Barré E, et al. Long-term safety and efficacy of abatacept in patients with rheumatoid arthritis and an inadequate response to methotrexate: a 7-year extended study. Clin Exp Rheumatol 2014;32:553-62.
Fleischmann R, van Vollenhoven RF, Vencovsky J, Alten R, Davies O, Mountian I, et al. Longterm maintenance of certolizumab pegol safety and efficacy, in combination with methotrexate and as monotherapy, in rheumatoid arthritis patients. Rheumatol Ther 2017;4:57-69.
Mary J, De Bandt M, Lukas C, Morel J, Combe B. Triple oral therapy versus antitumor necrosis factor plus methotrexate (MTX) in patients with rheumatoid arthritis and ınadequate response to MTX: a systematic literature review. J Rheumatol 2017;44:773-9.
Hazlewood GS, Barnabe C, Tomlinson G, Marshall D, Devoe DJ, Bombardier C. Methotrexate monotherapy and methotrexate combination therapy with traditional and biologic disease modifying anti-rheumatic drugs for rheumatoid arthritis: A network meta-analysis. Cochrane Database Syst Rev 2016;8:CD010227.
Peper SM, Lew R, Mikuls T, Brophy M, Rybin D, Wu H, et al. Rheumatoid arthritis treatment after methotrexate: the durability of triple therapy versus etanercept. Arthritis Care Res (Hoboken) 2017;69:1467-72.
O’Dell JR, Mikuls TR, Taylor TH, Ahluwalia V, Brophy M, Warren SR, et al. Therapies for active rheumatoid arthritis after methotrexate failure. N Engl J Med 2013;369:307-18.
Sauer BC, Teng CC, Tang D, Leng J, Curtis JR, Mikuls TR, et al. Persistence with conventional triple therapy versus a tumor necrosis factor inhibitor and methotrexate in US veterans with rheumatoid arthritis. Arthritis Care Res (Hoboken) 2017;69:313-22
McQueen FM, Benton N, Perry D, Crabbe J, Robinson E, Yeoman S, et al. Bone edema scored on magnetic resonance imaging scans of the dominant carpus at presentation predicts radiographic joint damage of the hands and feet six years later in patients with rheumatoid arthritis. Arthritis Rheum 2003;48:1814-27.
Haavardsholm EA, Bøyesen P, Østergaard M, Schildvold A, Kvien TK. Magnetic resonance imaging findings in 84 patients with early rheumatoid arthritis: bone marrow oedema predicts erosive progression. Ann Rheum Dis 2008;67:794-800.
Hetland ML, Ejbjerg B, Hørslev-Petersen K, Jacobsen S, Vestergaard A, Jurik AG, et al. MRI bone oedema is the strongest predictor of subsequent radiographic progression in early rheumatoid arthritis. Results from a 2-year randomised controlled trial (CIMESTRA). Ann Rheum Dis 2009;68:384-90.
Sreerangaiah D, Grayer M, Fisher BA, Ho M, Abraham S, Taylor PC. Quantitative power Doppler ultrasound measures of peripheral joint synovitis in poor prognosis early rheumatoid arthritis predict radiographic progression. Rheumatology (Oxford) 2016;55:89-93.
Naredo E, Collado P, Cruz A, Palop MJ, Cabero F, Richi P, et al. Longitudinal power Doppler ultrasonographic assessment of joint inflammatory activity in early rheumatoid arthritis: predictive value in disease activity and radiologic progression. Arthritis Rheum 2007;57:116-24.
Saevarsdottir S, Rezaei H, Geborek P, Petersson I, Ernestam S, Albertsson K, et al. Current smoking status is a strong predictor of radiographic progression in early rheumatoid arthritis: Results from the SWEFOT trial. Ann Rheum Dis 2015;74:1509-14.
van Leeuwen MA, van Rijswijk MH, Sluiter WJ, van Riel PL, Kuper IH, van de Putte LB, et al. Individual relationship between progression of radiological damage and the acute phase response in early rheumatoid arthritis. Towards development of a decision support system. J Rheumatol 1997;24:20-7.
van der Heijde DM, van Riel PL, van Leeuwen MA, van ‘t Hof MA, van Rijswijk MH, van de Putte LB. Prognostic factors for radiographic damage and physical disability in early rheumatoid arthritis. A prospective follow-up study of 147 patients. Br J Rheumatol 1992;31:519-25.
Smolen JS, Van Der Heijde DM, St Clair EW, Emery P, Bathon JM, Keystone E, et al. Predictors of joint damage in patients with early rheumatoid arthritis treated with high-dose methotrexate with or without concomitant infliximab: Results from the ASPIRE trial. Arthritis Rheum 2006;54:702-10
To evaluate the efficacy and safety of sunpharma 1505 compared with reference 1505 in subjects with active rheumatoid arthritis. Available from: https:// clinicaltrials.gov/ct2/show/NCT02534896. [Access date: February 10. 2018]
Buttgereit F, Strand V, Lee EB, McCabe D, Kolluri S, Tammara B. Efficacy and safety of PF-04171327, a novel dissociated agonist of the glucocorticoid receptor (DAGR): Results of a phase 2, randomized, double-blind study. Ann Rheum Dis. 2015;74:737–38.
Palmowski Y, Buttgereit T, Dejaco C, Bijlsma JW, Matteson EL, Voshaar M, et al. “Official View” on Glucocorticoids in Rheumatoid Arthritis: A Systematic Review of International Guidelines and Consensus Statements. Arthritis Care Res (Hoboken) 2017;69:1134-41.
Buttgereit F, Mehta D, Kirwan J, Szechinski J, Boers M, Alten RE, et al. Low-dose prednisone chronotherapy for rheumatoid arthritis: a randomised clinical trial (CAPRA-2). Ann Rheum Dis 2013;72:204-10.
Paolino S, Cutolo M, Pizzorni C. Glucocorticoid management in rheumatoid arthritis: morning or night low dose? Reumatologia 2017;55:189-97.
Strangfeld A, Eveslage M, Schneider M, Bergerhausen HJ, Klopsch T, Zink A, et al. Treatment benefit or survival of the fittest: what drives the timedependent decrease in serious infection rates under TNF inhibition and what does this imply for the individual patient? Ann Rheum Dis 2011;70:1914-20.
Sihvonen S, Korpela M, Mustonen J, Huhtala H, Karstila K, Pasternack A. Mortality in patients with rheumatoid arthritis treated with low-dose oral glucocorticoids. A population-based cohort study. J Rheumatol 2006;33:1740-6.
Wei L, MacDonald TM, Walker BR. Taking glucocorticoids by prescription is associated with subsequent cardiovascular disease. Ann Intern Med 2004;141:764-70.
Davis JM, Maradit Kremers H, Crowson CS, Nicola PJ, Ballman KV, Therneau TM, et al. Glucocorticoids and cardiovascular events in rheumatoid arthritis: a population-based cohort study. Arthritis Rheum 2007;56:820-30.
Borresen SW, Klose M, Baslund B, Rasmussen ÅK, Hilsted L, Friis-Hansen L, et al. Adrenal insufficiency is seen in more than one-third of patients during ongoing low-dose prednisolone treatment for rheumatoid arthritis. Eur J Endocrinol 2017;177:287-295.
Smolen JS, Kalden JR, Scott DL, Rozman B, Kvien TK, Larsen A, et al. Efficacy and safety of leflunomide compared with placebo and sulphasalazine in active rheumatoid arthritis: a double-blind, randomised, multicentre trial. European Leflunomide Study Group. Lancet 1999;353:259-66.
Alfaro-Lara R, Espinosa-Ortega HF, Arce-Salinas CA. Systematic review and meta-analysis of the efficacy and safety of leflunomide and methotrexate in the treatment of rheumatoid arthritis. Reumatol Clin 2017. pii: S1699-258X(17)30196-1.
Golicki D, Newada M, Lis J, Pol K, Hermanowski T, Tlustochowicz M. Leflunomide in monotherapy of rheumatoid arthritis: meta-analysis of randomized trials. Pol Arch Med Wewn 2012;122:22-32.
Hage MP, Al-Badri MR, Azar ST. A favorable effect of hydroxychloroquine on glucose and lipid metabolism beyond its anti-inflammatory role. Ther Adv Endocrinol Metab 2014;5:77-85.
Singh JA, Hossain A, Mudano AS, Tanjong Ghogomu E, Suarez-Almazor ME, Buchbinder R, et al. Biologics or tofacitinib for people with rheumatoid arthritis naive to methotrexate: a systematic review and network meta-analysis. Cochrane Database Syst Rev 2017 8;5:CD012657.
Gaujoux-Viala C, Rincheval N, Dougados M, Combe B, Fautrel B. Optimal methotrexate dose is associated with better clinical outcomes than non-optimal dose in daily practice: Results from the espoir early arthritis cohort. Ann Rheum Dis 2017;76:2054-60.
Visser K, Katchamart W, Loza E, Martinez-Lopez JA, Salliot C, Trudeau J, et al. Multinational evidencebased recommendations for the use of methotrexate in rheumatic disorders with a focus on rheumatoid arthritis: integrating systematic literature research and expert opinion of a broad international panel of rheumatologists in the 3E Initiative. Ann Rheum Dis 2009;68:1086-93.
Braun J, Kästner P, Flaxenberg P, Währisch J, Hanke P, Demary W, et al. Comparison of the clinical efficacy and safety of subcutaneous versus oral administration of methotrexate in patients with active rheumatoid arthritis: results of a six-month, multicenter, randomized, double-blind, controlled, phase IV trial. Arthritis Rheum 2008;58:73-81.
Schiff MH, Jaffe JS, Freundlich B.Head-tohead, randomised, crossover study of oral versus subcutaneous methotrexate in patients with rheumatoid arthritis: drug-exposure limitations of oral methotrexate at doses ≥15 mg may be overcome with subcutaneous administration. Ann Rheum Dis 2014;73:1549-51
Aletaha D, Smolen J. The Simplified Disease Activity Index (SDAI) and the Clinical Disease Activity Index (CDAI): a review of their usefulness and validity in rheumatoid arthritis. Clin Exp Rheumatol 2005;23:100-8.
Dhaon P, Das SK, Srivastava R, Dhakad U. Performances of Clinical Disease Activity Index (CDAI) and Simplified Disease Activity Index (SDAI) appear to be better than the gold standard Disease Assessment Score (DAS-28-CRP) to assess rheumatoid arthritis patients. Int J Rheum Dis 2017.
Salaffi F, Di Carlo M, Iannone F, Fedele AL, Epis OM, Pellerito R, et al. The UltraSound-CLinical ARthritis Activity (US-CLARA) index: Properties of a new composite disease activity index for rheumatoid arthritis. Semin Arthritis Rheum 2018;47:619-29.
Schoels M, Alasti F, Smolen JS, Aletaha D. Evaluation of newly proposed remission cut-points for disease activity score in 28 joints (DAS28) in rheumatoid arthritis patients upon IL-6 pathway inhibition. Arthritis Res Ther 2017;19:155.
Fleischmann R, van der Heijde D, Koenig AS, Pedersen R, Szumski A, Marshall L, et al. How much does Disease Activity Score in 28 joints ESR and CRP calculations underestimate disease activity compared with the Simplified Disease Activity Index? Ann Rheum Dis 2015;74:1132-7.
Kawashiri SY, Kawakami A, Iwamoto N, Fujikawa K, Aramaki T, Tamai M, et al. Disease activity score 28 may overestimate the remission induction of rheumatoid arthritis patients treated with tocilizumab: comparison with the remission by the clinical disease activity index. Mod Rheumatol 2011;21:365-9.
de Punder YM, Hendrikx J, den Broeder AA, Valls Pascual E, van Riel PL, Fransen J. Should we redefine treatment targets in rheumatoid arthritis? Low disease activity is sufficiently strict for patients who are anticitrullinated protein antibody-negative. J Rheumatol 2013;40:1268-74.
Smolen JS, Breedveld FC, Burmester GR, Bykerk V, Dougados M, Emery P, et al. Treating rheumatoid arthritis to target: 2014 update of the recommendations of an international task force. Ann Rheum Dis 2016;75:3-15.
Mathew AJ, Danda D, Conaghan PG. MRI and ultrasound in rheumatoid arthritis. Curr Opin Rheumatol 2016;28:323-9.
Smolen JS, Aletaha D, McInnes IB. Rheumatoid arthritis. Lancet 2016;388:2023-38.
Aletaha D, Neogi T, Silman AJ, Funovits J, Felson DT, Bingham CO, et al. 2010 rheumatoid arthritis classification criteria: an American College of Rheumatology/European League Against Rheumatism collaborative initiative. Ann Rheum Dis 2010;69:1580-8
Combe B. Progression in early rheumatoid arthritis. Best Pract Res Clin Rheumatol 2009;23:59-69.
El Miedany Y, Youssef S, Mehanna AN, El Gaafary M. Development of a scoring system for assessment of outcome of early undifferentiated inflammatory synovitis. Joint Bone Spine 2008;75:155-62.
Rat AC, Boissier MC. Rheumatoid arthritis: direct and indirect costs. Joint Bone Spine 2004;71:518-24
Athanasakis K, Tarantilis F, Tsalapati K, Konstantopoulou T, Vritzali E, Kyriopoulos J. Costutility analysis of tocilizumab monotherapy in first line versus standard of care for the treatment of rheumatoid arthritis in Greece. Rheumatol Int 2015;35:1489-95.
Ikeda K, Iwamoto T, Nakajima H. Perspective of ultrasound-guided strategy to reduce/discontinue biologics. Nihon Rinsho 2016;74:919-23. [Abstract]
Gabriel SE, Coyle D, Moreland LW. A clinical and economic review of disease-modifying antirheumatic drugs. Pharmacoeconomics 2001;19:715-28.
Allaire SH, Prashker MJ, Meenan RF. The costs of rheumatoid arthritis. Pharmacoeconomics 1994;6:513-22.
Hifinger M, Hiligsmann M, Ramiro S, Watson V, Severens JL, Fautrel B, et al. Economic considerations and patients' preferences affect treatment selection for patients with rheumatoid arthritis: a discrete choice experiment among European rheumatologists. Ann Rheum Dis 2017;76:126-32.
Masiero S, Boniolo A, Wassermann L, Machiedo H, Volante D, Punzi L. Effects of an educationalbehavioral joint protection program on people with moderate to severe rheumatoid arthritis: a randomized controlled trial. Clin Rheumatol 2007;26:2043-50.
Hammond A, Freeman K. One-year outcomes of a randomized controlled trial of an educationalbehavioural joint protection programme for people with rheumatoid arthritis. Rheumatology (Oxford) 2001;40:1044-51.
Riemsma RP, Kirwan JR, Taal E, Rasker JJ. Patient education for adults with rheumatoid arthritis. Cochrane Database Syst Rev 2003;2:CD003688.
Brozek JL, Akl EA, Alonso-Coello P, Lang D, Jaeschke R, Williams JW, et al. Grading quality of evidence and strength of recommendations in clinical practice guidelines. Part 1 of 3. An overview of the GRADE approach and grading quality of evidence about interventions. Allergy 2009;64:669-77.
Ataman , Sarı Zühre S, ‹smihan S, Özdemirel E, Akıncı T, Bodur H, et al. Turkish Compliance and Adaptation of EULAR 2013 Recommendations for the Management of Rheumatoid Arthritis with Synthetic and Biological Disease-modifying Antirheumatic Drugs: Expert opinion of TLAR. Arch Rheumatol 2015;30:271-84.
Ataman , Borman P, Evcik D, Aydo¤ E, Ayhan F, Yıldızlar D, et al. Management of rheumatoid arthritis: Consensus Recommendations from the Turkish League Against Rheumatism. Turk J Rheumatol 2011;26:273-94.
Singh JA, Saag KG, Bridges SL Jr, Akl EA, Bannuru RR, Sullivan MC, et al. 2015 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis. Arthritis Rheumatol 2016;68:1-26.
Singh JA, Furst DE, Bharat A, Curtis JR, Kavanaugh AF, Kremer JM, et al. 2012 update of the 2008 American College of Rheumatology recommendations for the use of disease-modifying antirheumatic drugs and biologic agents in the treatment of rheumatoid arthritis. Arthritis Care Res (Hoboken) 2012;64:625-39.
Saag KG, Teng GG, Patkar NM, Anuntiyo J, Finney C, Curtis JR, et al. American College of Rheumatology 2008 recommendations for the use of nonbiologic and biologic disease-modifying antirheumatic drugs in rheumatoid arthritis. Arthritis Rheum 2008;59:762-84.
Smolen JS, Landewé R, Bijlsma J, Burmester G, Chatzidionysiou K, Dougados M, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological diseasemodifying antirheumatic drugs: 2016 update. Ann Rheum Dis 2017;76:960-77.
Smolen JS, Landewé R, Breedveld FC, Buch M, Burmester G, Dougados M, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological diseasemodifying antirheumatic drugs: 2013 update. Ann Rheum Dis 2014;73:492-509.
Smolen JS, Landewé R, Breedveld FC, Dougados M, Emery P, Gaujoux-Viala C, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological diseasemodifying antirheumatic drugs. Ann Rheum Dis 2010;69:964-75.
Smolen JS, van der Heijde D, Machold KP, Aletaha D, Landewé R. Proposal for a new nomenclature of disease-modifying antirheumatic drugs. Ann Rheum Dis 2014;73:3-5.
Smolen JS, Aletaha D, Koeller M, Weisman MH, Emery P. New therapies for treatment of rheumatoid arthritis. Lancet 2007;370:1861-74.
Arora S, Rafiq A, Jolly M. Management of rheumatoid arthritis: Review of current guidelines. Journal of Arthroscopy and Joint Surgery 2016;3:45-50.

APA	ATAMAN Ş, Sunar İ, yılmaz g, Bodur H, NAS K, AYHAN F, Akgul O, AKINCI A, ALTAY Z, BİRTANE M, SOY BUĞDAYCI D, ÇAPKIN E, ÇEVİK R, ÇİMEN Y, DURUÖZ M, ELHAN A, gurer g, KAÇAR C, KAMANLI A, KAPTANOĞLU E, Kaya T, KOCABAŞ H, Kuru O, ALKAN MELİKOĞLU M, OZEL S, rezvani a, SEZER İ, GÜL YURDAKUL F (2018). Turkish League Against Rheumatism (TLAR) Recommendations for the Pharmacological Management of Rheumatoid Arthritis: 2018 Update Under Guidance of Current Recommendations. , 251 - 272.
Chicago	ATAMAN Şebnem,Sunar İsmihan,yılmaz gürkan,Bodur Hatice,NAS Kemal,AYHAN Fikriye Figen,Akgul Ozgur,AKINCI Ayşen,ALTAY ZÜHAL,BİRTANE Murat,SOY BUĞDAYCI Derya,ÇAPKIN Erhan,ÇEVİK REMZİ,ÇİMEN Yeşim Garip,DURUÖZ M. Tuncay,ELHAN Atilla Halil,gurer gülcan,KAÇAR Cahit,KAMANLI Ayhan,KAPTANOĞLU Ece,Kaya Taciser,KOCABAŞ Hilal,Kuru Omer,ALKAN MELİKOĞLU Meltem,OZEL SUMRU,rezvani aylin,SEZER İlhan,GÜL YURDAKUL Fatma Turkish League Against Rheumatism (TLAR) Recommendations for the Pharmacological Management of Rheumatoid Arthritis: 2018 Update Under Guidance of Current Recommendations. (2018): 251 - 272.
MLA	ATAMAN Şebnem,Sunar İsmihan,yılmaz gürkan,Bodur Hatice,NAS Kemal,AYHAN Fikriye Figen,Akgul Ozgur,AKINCI Ayşen,ALTAY ZÜHAL,BİRTANE Murat,SOY BUĞDAYCI Derya,ÇAPKIN Erhan,ÇEVİK REMZİ,ÇİMEN Yeşim Garip,DURUÖZ M. Tuncay,ELHAN Atilla Halil,gurer gülcan,KAÇAR Cahit,KAMANLI Ayhan,KAPTANOĞLU Ece,Kaya Taciser,KOCABAŞ Hilal,Kuru Omer,ALKAN MELİKOĞLU Meltem,OZEL SUMRU,rezvani aylin,SEZER İlhan,GÜL YURDAKUL Fatma Turkish League Against Rheumatism (TLAR) Recommendations for the Pharmacological Management of Rheumatoid Arthritis: 2018 Update Under Guidance of Current Recommendations. , 2018, ss.251 - 272.
AMA	ATAMAN Ş,Sunar İ,yılmaz g,Bodur H,NAS K,AYHAN F,Akgul O,AKINCI A,ALTAY Z,BİRTANE M,SOY BUĞDAYCI D,ÇAPKIN E,ÇEVİK R,ÇİMEN Y,DURUÖZ M,ELHAN A,gurer g,KAÇAR C,KAMANLI A,KAPTANOĞLU E,Kaya T,KOCABAŞ H,Kuru O,ALKAN MELİKOĞLU M,OZEL S,rezvani a,SEZER İ,GÜL YURDAKUL F Turkish League Against Rheumatism (TLAR) Recommendations for the Pharmacological Management of Rheumatoid Arthritis: 2018 Update Under Guidance of Current Recommendations. . 2018; 251 - 272.
Vancouver	ATAMAN Ş,Sunar İ,yılmaz g,Bodur H,NAS K,AYHAN F,Akgul O,AKINCI A,ALTAY Z,BİRTANE M,SOY BUĞDAYCI D,ÇAPKIN E,ÇEVİK R,ÇİMEN Y,DURUÖZ M,ELHAN A,gurer g,KAÇAR C,KAMANLI A,KAPTANOĞLU E,Kaya T,KOCABAŞ H,Kuru O,ALKAN MELİKOĞLU M,OZEL S,rezvani a,SEZER İ,GÜL YURDAKUL F Turkish League Against Rheumatism (TLAR) Recommendations for the Pharmacological Management of Rheumatoid Arthritis: 2018 Update Under Guidance of Current Recommendations. . 2018; 251 - 272.
IEEE	ATAMAN Ş,Sunar İ,yılmaz g,Bodur H,NAS K,AYHAN F,Akgul O,AKINCI A,ALTAY Z,BİRTANE M,SOY BUĞDAYCI D,ÇAPKIN E,ÇEVİK R,ÇİMEN Y,DURUÖZ M,ELHAN A,gurer g,KAÇAR C,KAMANLI A,KAPTANOĞLU E,Kaya T,KOCABAŞ H,Kuru O,ALKAN MELİKOĞLU M,OZEL S,rezvani a,SEZER İ,GÜL YURDAKUL F "Turkish League Against Rheumatism (TLAR) Recommendations for the Pharmacological Management of Rheumatoid Arthritis: 2018 Update Under Guidance of Current Recommendations." , ss.251 - 272, 2018.
ISNAD	ATAMAN, Şebnem vd. "Turkish League Against Rheumatism (TLAR) Recommendations for the Pharmacological Management of Rheumatoid Arthritis: 2018 Update Under Guidance of Current Recommendations". (2018), 251-272.

APA	ATAMAN Ş, Sunar İ, yılmaz g, Bodur H, NAS K, AYHAN F, Akgul O, AKINCI A, ALTAY Z, BİRTANE M, SOY BUĞDAYCI D, ÇAPKIN E, ÇEVİK R, ÇİMEN Y, DURUÖZ M, ELHAN A, gurer g, KAÇAR C, KAMANLI A, KAPTANOĞLU E, Kaya T, KOCABAŞ H, Kuru O, ALKAN MELİKOĞLU M, OZEL S, rezvani a, SEZER İ, GÜL YURDAKUL F (2018). Turkish League Against Rheumatism (TLAR) Recommendations for the Pharmacological Management of Rheumatoid Arthritis: 2018 Update Under Guidance of Current Recommendations. Archives of Rheumatology, 33(3), 251 - 272.
Chicago	ATAMAN Şebnem,Sunar İsmihan,yılmaz gürkan,Bodur Hatice,NAS Kemal,AYHAN Fikriye Figen,Akgul Ozgur,AKINCI Ayşen,ALTAY ZÜHAL,BİRTANE Murat,SOY BUĞDAYCI Derya,ÇAPKIN Erhan,ÇEVİK REMZİ,ÇİMEN Yeşim Garip,DURUÖZ M. Tuncay,ELHAN Atilla Halil,gurer gülcan,KAÇAR Cahit,KAMANLI Ayhan,KAPTANOĞLU Ece,Kaya Taciser,KOCABAŞ Hilal,Kuru Omer,ALKAN MELİKOĞLU Meltem,OZEL SUMRU,rezvani aylin,SEZER İlhan,GÜL YURDAKUL Fatma Turkish League Against Rheumatism (TLAR) Recommendations for the Pharmacological Management of Rheumatoid Arthritis: 2018 Update Under Guidance of Current Recommendations. Archives of Rheumatology 33, no.3 (2018): 251 - 272.
MLA	ATAMAN Şebnem,Sunar İsmihan,yılmaz gürkan,Bodur Hatice,NAS Kemal,AYHAN Fikriye Figen,Akgul Ozgur,AKINCI Ayşen,ALTAY ZÜHAL,BİRTANE Murat,SOY BUĞDAYCI Derya,ÇAPKIN Erhan,ÇEVİK REMZİ,ÇİMEN Yeşim Garip,DURUÖZ M. Tuncay,ELHAN Atilla Halil,gurer gülcan,KAÇAR Cahit,KAMANLI Ayhan,KAPTANOĞLU Ece,Kaya Taciser,KOCABAŞ Hilal,Kuru Omer,ALKAN MELİKOĞLU Meltem,OZEL SUMRU,rezvani aylin,SEZER İlhan,GÜL YURDAKUL Fatma Turkish League Against Rheumatism (TLAR) Recommendations for the Pharmacological Management of Rheumatoid Arthritis: 2018 Update Under Guidance of Current Recommendations. Archives of Rheumatology, vol.33, no.3, 2018, ss.251 - 272.
AMA	ATAMAN Ş,Sunar İ,yılmaz g,Bodur H,NAS K,AYHAN F,Akgul O,AKINCI A,ALTAY Z,BİRTANE M,SOY BUĞDAYCI D,ÇAPKIN E,ÇEVİK R,ÇİMEN Y,DURUÖZ M,ELHAN A,gurer g,KAÇAR C,KAMANLI A,KAPTANOĞLU E,Kaya T,KOCABAŞ H,Kuru O,ALKAN MELİKOĞLU M,OZEL S,rezvani a,SEZER İ,GÜL YURDAKUL F Turkish League Against Rheumatism (TLAR) Recommendations for the Pharmacological Management of Rheumatoid Arthritis: 2018 Update Under Guidance of Current Recommendations. Archives of Rheumatology. 2018; 33(3): 251 - 272.
Vancouver	ATAMAN Ş,Sunar İ,yılmaz g,Bodur H,NAS K,AYHAN F,Akgul O,AKINCI A,ALTAY Z,BİRTANE M,SOY BUĞDAYCI D,ÇAPKIN E,ÇEVİK R,ÇİMEN Y,DURUÖZ M,ELHAN A,gurer g,KAÇAR C,KAMANLI A,KAPTANOĞLU E,Kaya T,KOCABAŞ H,Kuru O,ALKAN MELİKOĞLU M,OZEL S,rezvani a,SEZER İ,GÜL YURDAKUL F Turkish League Against Rheumatism (TLAR) Recommendations for the Pharmacological Management of Rheumatoid Arthritis: 2018 Update Under Guidance of Current Recommendations. Archives of Rheumatology. 2018; 33(3): 251 - 272.
IEEE	ATAMAN Ş,Sunar İ,yılmaz g,Bodur H,NAS K,AYHAN F,Akgul O,AKINCI A,ALTAY Z,BİRTANE M,SOY BUĞDAYCI D,ÇAPKIN E,ÇEVİK R,ÇİMEN Y,DURUÖZ M,ELHAN A,gurer g,KAÇAR C,KAMANLI A,KAPTANOĞLU E,Kaya T,KOCABAŞ H,Kuru O,ALKAN MELİKOĞLU M,OZEL S,rezvani a,SEZER İ,GÜL YURDAKUL F "Turkish League Against Rheumatism (TLAR) Recommendations for the Pharmacological Management of Rheumatoid Arthritis: 2018 Update Under Guidance of Current Recommendations." Archives of Rheumatology, 33, ss.251 - 272, 2018.
ISNAD	ATAMAN, Şebnem vd. "Turkish League Against Rheumatism (TLAR) Recommendations for the Pharmacological Management of Rheumatoid Arthritis: 2018 Update Under Guidance of Current Recommendations". Archives of Rheumatology 33/3 (2018), 251-272.