Table 2 Overarching principles and treat-to-target strategy

General considerations

1. RA patients should be looked after by rheumatologists

2. RA diagnosis is mainly clinical depending on the evaluation of an expert rheumatologist (some aiding tools such as musculoskeletal ultrasound (MSUS) could aid in the diagnosis and disease assessment). The classification criteria are for classifying the disease not for diagnosis

3. Continuous assessment of RA patient regarding (prognostic factors, disease activity, and severity & functional status) is important for optimum management decision

4. Ultrasound can be used in routine monitoring of disease activity, adjustment of the DMARD dose, or guided local injection in adults with RA

5. Treatment should be started as soon as the diagnosis of RA is made

6. Treatment should be individualized to meet the patient requirement

7. Treatment of patients with RA should be based on a shared decision between the patient and the rheumatologist

8. When choosing a treatment plans, consider the patient’s motivation, comorbidities, functional ability, structural damage development (as determined by imaging or sonography), and disease activity level

9. Early in the treatment course, rheumatologist should frequently monitor the active disease (every 1–3 months) and then get less frequent (every 3–6 months)

10. Clinical and ultrasound disease activity should be assessed regularly

11. Within 3 months of treatment, at least a 50% improvement in disease activity should be reached and the target within 6 months

12. Adequate response to treatment at 6 months is considered if DAS-28 score improved by 1.2

13. Treatment should be continuously adjusted until achieving the target

14. Once the treatment target has been achieved, it should be sustained. Continuous monitoring should be carried out to ensure maintenance of the target

15. Regular assessment of comorbidities is essential in the management strategy

8.27 ± 1.7

100

H

Treat-to-target strategy

1. Treat-to-target strategies: sustained clinical remission (as defined by the American College of Rheumatology-(ACR)-EULAR Boolean or index criteria) or low disease activity is advised to be adopted

2. Controlling signs and symptoms, avoiding structural damage, comorbid conditions, drug toxicity, and optimizing function, growth and development, quality of life, and social engagement are the main objectives of treating RA patients

3. Whenever feasible, it is desirable to adopt the least expensive kind of treatment

4. Before cDMARD therapy, all the patients should be screed for full blood count, liver and kidney functions, and hepatitis C and hepatitis B status. Baseline chest X-ray is also advised. Before commencing biologic therapy, all the patients should have the above-mentioned tests as well as test for latent tuberculosis (T-spot/IGRA test)

5. MTX should be part of the first treatment strategy

6. Treat to target involves monitoring disease activity often and modifying the therapy as necessary to meet treatment objectives

7. Disease SUSTAINED remission is the main goal for treating RA patients (clinical, ultrasonographic, and functional)

8. Another goal is to achieve minimal (or low) disease activity, which is measured by clinical, ultrasonographic, and functional measures, especially in individuals with refractory, chronic diseases

9. For those who have a higher risk of radiological advancement, think about making remission the aim rather than minimal disease activity (the presence of anti-CCP antibodies or erosions on X-ray at baseline assessment)

10. Until the goal of remission or low disease activity is achieved, measure C-reactive protein (CRP) and disease activity (using a composite score such the DAS-28) monthly in a specialist care programme for persons with active RA

11. Difficult to treat/refractory arthritis cases should be identified, assessed for the underlying causes, and managed on individual bases

8.55 ± 0.61

100

H