Rheumatoid arthritis — guideline registry¶
Last checked: 2026-10-25. This catalogue records documents; recommendation synthesis is in wiki/guidelines.md. New PubMed identifiers are admitted only after live retrieval.
Master table¶
| Body | Year | Region | Scope | Citation | Status |
|---|---|---|---|---|---|
| EULAR | 2025 | Europe/international | Pharmacologic RA management | Smolen et al., PMID 41826212 | current; published 2026 |
| EULAR | 2022 | Europe/international | Pharmacologic RA management | Smolen et al., PMID 36357155 | superseded by → EULAR 2025 |
| EULAR | 2019 | Europe/international | Pharmacologic RA management | Smolen et al., PMID 31969328 | superseded by → EULAR 2022 |
| EULAR | 2016 | Europe/international | Pharmacologic RA management | Smolen et al., PMID 28264816 | superseded by → EULAR 2019 → 2022 |
| ACR | 2021 | US | Pharmacologic RA treatment | Fraenkel et al., PMID 34101376 | current pharmacologic guideline; predates final ORAL Surveillance |
| ACR | 2022 | US | Exercise, rehabilitation, diet, integrative care | England et al., PMID 37227116 | current |
| ACR | 2022 | US | Vaccination in rheumatic and musculoskeletal disease | Bass et al., PMID 36597813 | current |
| ACR | 2020 | US | Reproductive health in rheumatic disease | Sammaritano et al., PMID 32090466 | current |
| EULAR | 2019 | Europe/international | Vaccination in adult autoimmune inflammatory rheumatic disease | Furer et al., PMID 31413005 | current vaccination framework |
| EULAR | 2021 | Europe/international | Lifestyle behaviours and work participation | Gwinnutt et al., PMID 35260387 | current |
| EULAR | 2022 | Europe/international | Cardiovascular risk management in rheumatic disease | Drosos et al., PMID 35110331 | current |
| ACR/EULAR | 2022 | International | Remission definition | Studenic et al., PMID 36274193 | current |
| EULAR | 2021 | Europe/international | Difficult-to-treat RA | Nagy et al., PMID 34407926 | current points to consider |
| ACR/CHEST | 2023 | US/international | Systemic-autoimmune ILD screening and monitoring, including RA-ILD | Johnson et al., PMID 38973714 | current; published 2024 |
| ACR/CHEST | 2023 | US/international | Systemic-autoimmune ILD treatment, including RA-ILD | Johnson et al., PMID 38973731 | current; published 2024; conditional RA-ILD evidence |
| French Society of Rheumatology | 2024 | France | Diagnosis, treatment, at-risk RA and RA-ILD | Fautrel et al., PMID 39389412 | current |
| Mexican College of Rheumatology | 2023 | Mexico | Pharmacologic RA management | Abud-Mendoza et al., PMID 38796394 | current |
| Japan College of Rheumatology | 2024 | Japan | RA management | Harigai et al., PMID 39820350 | current |
| APLAR | 2024 | Asia-Pacific | RA management, infection, vaccination and pregnancy | Yamaoka et al., PMID 42362943 | current; published 2026 |
| ALAT | 2025 | Latin America | RA-ILD recognition and management | Alberti et al., PMID 42034552 | current; published 2026 |
| British Society for Rheumatology | 2026 | UK | Pain management across inflammatory arthritis, including RA | Scott et al., PMID 42476581 | current adjunct guideline |
| DGRh | 2026 | Germany | S3 pharmacologic RA management, including de-escalation and RA-ILD | https://register.awmf.org/de/leitlinien/detail/060-004 (accessed 2026-10-11) | current; supersedes 2018 S2e guideline |
| South African Rheumatism and Arthritis Association | 2024 | South Africa | RA management | https://www.scielo.org.za/scielo.php?pid=S0256-95742024001000006&script=sci_arttext (accessed 2026-08-30) | current |
| Royal Dutch Society for Physical Therapy | 2020/2021 | Netherlands | Physical-therapy management | Hurkmans et al., PMID 34003240 | current |
| EULAR | 2010 | Europe/international | Treat-to-target recommendations | Smolen et al., PMID 22089062 | historical; incorporated into later management updates |
| ACR/EULAR | 2010 | International | Classification | Aletaha et al., PMID 20872595 | current classification framework |
| Italian Society of Rheumatology | 2026 | Italy | RA-ILD treatment | Crotti et al., PMID 41247141 | current; abstract describes three recommendation scenarios (RA drugs in RA-ILD, ILD drugs in RA-ILD, first-line failure) without item-level extraction |
| Expert RA-ILD group | 2026 | International | RA-ILD screening, diagnosis and treatment consensus | Solomon et al., PMID 42248165 | current expert consensus; does not replace ACR/CHEST |
| ERS/EULAR | 2025 | Europe/international | CTD-ILD screening, diagnosis, treatment and follow-up, including RA-ILD (25 PICO + 28 narrative questions) | Antoniou et al., PMID 40907995 (Eur Respir J); PMID 40912974 (Ann Rheum Dis) | current; co-published January 2026; added 2026-10-18 as a catch-up (missed by earlier sweeps) |
| PANLAR | 2025 | Latin America | Pharmacologic RA management; 10 recommendations and algorithm | Santos Moreno et al., PMID 41240967 | current; published January 2026; added 2026-10-18 as a catch-up |
| Argentine Society of Rheumatology | 2025 | Argentina | Pharmacologic RA treatment, Part I (21 GRADE recommendations) | Schneeberger et al., PMID 42507767 | current; published 2026; added 2026-10-18 as a catch-up |
| Argentine Society of Rheumatology | 2025 | Argentina | Part II: definitions, special situations and comorbidities (54 statements) | Schneeberger et al., PMID 42767235 | current; published September 2026 |
| Canadian Rheumatology Association | 2026 | Canada | Living RA guideline, update #3: tapering csDMARDs and b/tsDMARDs, including combination treatment | Nikolic et al., PMID 41921998 | current update; published August 2026; pre-window catch-up added 2026-10-25 |
Per-guideline notes¶
Canada 2026 living update and ERS/EULAR full-text follow-up¶
- The CRA update's recommendation table conditionally supports gradual dose reduction after at least six months of low activity/remission, with reliable access to care and prompt medication reinstatement after flare; either csDMARD or b/tsDMARD may be tapered first in combination treatment (Nikolic 2026, PMID 41921998). Recommendation table checked in full on 2026-10-25; moderate certainty.
- ERS/EULAR Table 1b recommends against replacing HRCT with PFTs in RA screening (PICO 2, strong/low certainty) and suggests against replacing HRCT with lung ultrasound (PICO 10, conditional/low certainty). Table 1c specifies established RA-ILD PFTs every 3–6 months for the first 1–2 years and at least every 6–12 months thereafter (NQ 21), with HRCT after 1–2 years and for suspected progression (NQ 25); both follow-up recommendations are conditional/very low certainty (Antoniou 2026, PMID 40907995). Full text checked 2026-10-25; these are monitoring intervals for diagnosed ILD, not repeat-screening intervals.
EULAR 2025 pharmacologic management¶
- Supersedes the 2022 pharmacologic document and preserves treat-to-target, methotrexate-centered initiation, risk-aware advanced-therapy selection and cautious tapering (Smolen 2026, PMID 41826212).
- The supporting efficacy review screened 12,567 references, included 72 studies, and found two antifibrotic RCT reports for RA-ILD and seven prevention studies through 22 January 2025 (Konzett 2026, PMID 41997804).
- The supporting safety review included 71 studies; much of the newer malignancy, cardiovascular and thromboembolic evidence was observational or claims-based, and it found no eligible DMARD-monitoring articles (Laskou 2026, PMID 41951459).
- Its publication date matters: unlike ACR 2021, it can incorporate the mature post-ORAL-Surveillance safety environment.
- Full implementation still depends on local approval, pricing, pregnancy plans, infection risk and comorbidity; the international algorithm is not a formulary.
EULAR 2022 pharmacologic management¶
- Starts methotrexate plus short-term glucocorticoids for most active RA.
- Assesses improvement by about three months and target by six months.
- Escalates to a biologic or JAK inhibitor after inadequate response, with JAK MACE/malignancy/VTE risk consideration.
- Supports cautious reduction only in sustained remission; complete cessation is generally discouraged.
- Evidence base: 169 articles selected from 8,969 results in the supporting efficacy review (Kerschbaumer 2023, PMID 36368906).
ACR 2021 pharmacologic treatment¶
- Uses GRADE and a clinician/patient voting panel.
- Favors methotrexate monotherapy in DMARD-naive moderate/high activity.
- Emphasizes methotrexate optimization and steroid minimization.
- Chronology caveat: publication preceded the final ORAL Surveillance report (Ytterberg 2022, PMID 35081280).
ACR 2022 integrative interventions¶
- Strongly recommends consistent exercise.
- Treats physical/occupational therapy, rehabilitation, diet and self-management as adjuncts to DMARDs, not substitutes.
- Separates evidence certainty from patient preference and feasibility.
Vaccination guidance: ACR 2022 and EULAR 2019¶
- ACR gives medication-specific advice, including temporary methotrexate management around influenza vaccination and timing around B-cell depletion (Bass 2023, PMID 36597813).
- EULAR emphasizes review before immunosuppression, non-live vaccines during therapy where indicated, and avoidance or individualized use of live vaccines under immunosuppression (Furer 2020, PMID 31413005).
- Neither document replaces national schedules; vaccine products, endemic exposures and age eligibility differ.
Reproductive health¶
- ACR 2020 distinguishes contraception, fertility, maternal and paternal exposure, pregnancy and lactation instead of assigning a single permanent pregnancy label to each DMARD (Sammaritano 2020, PMID 32090466).
- Low-certainty evidence and rapidly changing teratology registries make shared, preconception planning central.
Cardiovascular, lifestyle and work guidance¶
- EULAR cardiovascular guidance requires systematic risk recognition and management across inflammatory rheumatic disease, while the exact use of RA multipliers and reassessment intervals varies by national system (Drosos 2022, PMID 35110331).
- Lifestyle/work recommendations support physical activity, smoking cessation, healthy weight and work participation as longitudinal care, not substitutes for DMARDs (Gwinnutt 2023, PMID 35260387).
ACR/EULAR 2022 remission revision¶
- Boolean 2.0 retains tender joints ≤1, swollen joints ≤1 and CRP ≤1 mg/dL.
- Raises patient global threshold from ≤1 to ≤2 on a 0–10 scale.
- Keeps SDAI ≤3.3 as an index remission definition.
EULAR difficult-to-treat RA¶
- Reconfirm diagnosis and inflammatory activity.
- Assess adherence, comorbidity, pain mechanisms and access barriers.
- Switch mechanism when objective inflammatory disease persists rather than automatically cycling for symptoms alone.
ACR/CHEST RA-ILD framework¶
- Screening/monitoring guidance conditionally recommends PFTs and HRCT for at-risk patients and recommends against chest radiography, bronchoscopy and surgical biopsy as screening strategies (Johnson 2024, PMID 38973714).
- Conditionally supports mycophenolate, azathioprine and rituximab as first-line options.
- Includes cyclophosphamide and short-term glucocorticoids in selected cases.
- After progression, conditionally considers mycophenolate, rituximab, nintedanib, tocilizumab, cyclophosphamide and pirfenidone.
- Discourages long-term glucocorticoids for progressive fibrotic disease (Saavedra 2025, PMID 39822854).
France 2024¶
- Builds from EULAR 2022 while adding people at risk of RA and RA-ILD.
- Includes patient-association representatives in the working group.
- Requires local access and French care pathways for implementation.
Mexico 2023 and Japan 2024¶
- Both use structured evidence grading within different regulatory and access environments.
- They should not be reduced to copies of EULAR/ACR; local availability and approved doses differ.
Asia-Pacific, Latin American, European CTD-ILD, UK and South African additions¶
- APLAR 2024 supplies 14 consensus statements for the Asia-Pacific clinical landscape, including infection-reactivation and pregnancy decisions (Yamaoka 2026, PMID 42362943).
- ALAT 2025 is an official RA-ILD guideline emphasizing recognition, screening, articular control, DMARDs and antifibrotics (Alberti 2026, PMID 42034552).
- ERS/EULAR 2025 is the joint respiratory/rheumatology CTD-ILD guideline with RA-ILD-specific questions and GRADE-based algorithms; many recommendations carry low certainty (Antoniou 2026, PMID 40907995). A comparative review places it beside ACR/CHEST, EULAR, PANLAR and ALAT and finds the largest divergence on RA-ILD treatment and screening modality (Garcia-Salinas 2026, PMID 42888356).
- PANLAR 2025 gives ten pharmacologic recommendations and an algorithm for Latin America, explicitly weighting cost-effectiveness and access, with RA-ILD and vasculitis guidance (Santos Moreno 2026, PMID 41240967).
- The Argentine 2025 update has two parts: 21 GRADE recommendations from 71 PICO questions (Schneeberger 2026, PMID 42507767) and 54 statements on definitions and special situations, including a recommendation against treating asymptomatic high-risk people without arthritis, methotrexate for seropositive imaging-detected subclinical arthritis, non-TNF biologics in obesity and hepatitis B antiviral prophylaxis (Schneeberger 2026, PMID 42767235). Its systematic review searched LILACS; this repository cannot (SciELO/LILACS HTTP 403), so the Latin American evidence underneath it was not re-checked.
- The 2026 British Society for Rheumatology pain guideline spans inflammatory arthritis and supplies 23 recommendations; it is adjunct guidance, not an RA DMARD algorithm (Scott 2026, PMID 42476581).
- SARAA 2024 supplies a South African treatment and access context and was re-retrieved from the South African Medical Journal on 2026-08-30.
Germany 2026¶
- The DGRh S3 guideline replaces the 2018 S2e document and was verified through the official DGRh release and AWMF register on 2026-08-31.
- Active disease is assessed every one to three months; therapy changes when improvement is insufficient at three months or the target is missed at six months.
- Glucocorticoids are reduced rapidly and generally stopped within three months; sustained remission permits controlled DMARD reduction but not complete cessation.
- It adds a dedicated RA-ILD recommendation and calls for rheumatology–pulmonology coordination in progressive disease.
Disagreements and gaps¶
| Issue | Positions/gap | Why unresolved |
|---|---|---|
| Initial glucocorticoid bridge | EULAR more accepting; ACR more steroid-averse | Rapid benefit versus cumulative infection/bone harm |
| Initial triple therapy | Conditional differences in sequencing | Speed, pill burden, cost and preference |
| JAK placement | EULAR 2022 incorporates ORAL Surveillance; ACR 2021 predates it | Evidence chronology |
| Imaging-to-target | Not routinely recommended | Strategy trials did not improve outcomes |
| Drug taper order | No universal sequence | TARA found similar csDMARD-first/TNF-first strategies |
| RA-ILD screening | ACR/CHEST conditionally supports risk-based PFT/HRCT; a 1,156-person model has retrospective external validation (PMID 38973714; PMID 41299487) | A 2026-08-30 PubMed search retrieved no prospective comparison showing that a screening program improves outcomes |
| RA-ILD treatment | Mostly conditional | Sparse RA-specific randomized trials |
| Preclinical treatment | Not routine standard | Overtreatment and durability uncertain |
| Molecular treatment selector | None recommended routinely | No replicated utility trial |
| Vaccination medication holds | ACR gives drug-specific interruption advice; EULAR emphasizes timing and vaccine type | Flare risk, vaccine platform and immune response differ |
| Cardiovascular risk multiplier | Regional tools implement RA differently | Calibration and baseline event rates vary by population |
| Reproductive safety | Guideline and product-label wording can diverge | Observational exposure data and risk tolerance evolve |
Supersession chains¶
- EULAR pharmacologic: 2016 (PMID 28264816) → 2019 (PMID 31969328) → 2022 (PMID 36357155) → 2025 (PMID 41826212; published 2026).
- ACR pharmacologic: older documents are historical; 2021 (PMID 34101376) is the current PubMed-indexed treatment guideline in this registry, but requires post-ORAL-Surveillance interpretation.
- ACR/EULAR remission: provisional 2011 definitions → 2022 revision (PMID 36274193).
- German DGRh pharmacologic RA guidance: 2018 S2e → 2026 S3 (AWMF register 060-004).
Watch list¶
- Future ACR pharmacologic update incorporating ORAL Surveillance. The ACR RA guideline page retrieved 2026-10-25 still lists 2021 as the latest pharmacologic guideline.
- Implementation and independent appraisal of EULAR 2025 pharmacologic recommendations.
- Publication, implementation and independent appraisal of the DGRh 2026 S3 recommendations, especially its RA-ILD and de-escalation positions. A 2026-10-11 PubMed search still returned 0 DGRh S3 journal records.
- Item-level extraction of the 2026 Italian RA-ILD recommendations (Crotti, PMID 41247141); the PubMed abstract still does not list numbered drug recommendations.
- Prospective RA-ILD screening recommendations, including whether NCT07849673 reports outcome rather than process endpoints.
- Whether Solomon 2026 (PMID 42248165) is adopted or superseded by a society RA-ILD update.
- Prevention/interception guidance after longer ARIAA/APIPPRA follow-up.
- Regulatory changes for individual JAK inhibitors.