Clinical Guidelines in
Rheumatology & Immunology

The American College of Rheumatology 2021 guidelines recommend a treat-to-target (T2T) strategy aimed at achieving remission or low disease activity as measured by validated composite scores (DAS28, CDAI, SDAI). Methotrexate (MTX) remains the anchor DMARD, with combination csDMARD therapy preferred over monotherapy in moderate-to-high disease activity.

• Initiate MTX as first-line therapy unless contraindicated; target 20–25 mg/week
• Add HCQ ± SSZ in incomplete MTX responders before escalating to bDMARDs
• Use TNF inhibitors, abatacept, or JAK inhibitors for inadequate csDMARD response
• Reassess disease activity every 1–3 months; modify therapy if target not met in 3–6 months
• Screen all patients for TB, hepatitis B, hepatitis C before initiating bDMARDs or tsDMARDs

EULAR recommends treat-to-target with tight monitoring, a shared decision-making approach, and early aggressive intervention in newly diagnosed RA. Overarching principles emphasise the burden of RA and the right of patients to be involved in treatment decisions.

• Start csDMARDs immediately upon confirmed RA diagnosis; do not wait for specialist referral
• Bridging glucocorticoids at lowest effective dose for shortest possible duration
• bDMARDs/tsDMARDs indicated after failure of ≥2 csDMARD strategies including MTX
• JAK inhibitors: use with caution in patients >65 years, smokers, or those with cardiovascular risk
• Tapering biologics considered once sustained remission achieved ≥6 months

The 2019 EULAR/ACR classification criteria replace earlier criteria, using a weighted scoring system. EULAR 2023 management recommendations emphasise hydroxychloroquine (HCQ) as the universal background therapy for all SLE patients, aggressive organ-specific targets, and the use of belimumab as a steroid-sparing agent.

• HCQ 5 mg/kg/day (ideal body weight) — mandatory for all SLE patients unless contraindicated
• Target prednisone ≤7.5 mg/day as the maintenance dose; aim for steroid-free remission
• Mycophenolate mofetil (MMF) preferred over azathioprine for proliferative lupus nephritis induction
• Belimumab recommended as add-on therapy for persistently active SLE on standard therapy
• Annual ophthalmology review for all HCQ-treated patients; baseline OCT at initiation
• Antiphospholipid antibody panel at diagnosis in all patients

The updated ASAS-EULAR recommendations emphasise individualised treatment based on current symptoms (axial, peripheral, extra-articular), activity, prognostic factors, and patient preferences. NSAIDs remain the first-line pharmacological therapy.

• NSAIDs at full anti-inflammatory dose as first-line; continuous use only if persistent symptoms
• No established role for csDMARDs in purely axial disease (SSZ/MTX for peripheral arthritis only)
• bDMARD initiation (TNFi or IL-17i) after failure of ≥2 NSAIDs over 4 weeks each
• IL-17 inhibitors preferred over TNFi in patients with significant psoriasis or IBD is a contraindication
• Physiotherapy and exercise are essential, non-pharmacological cornerstones at all disease stages
• MRI spine and pelvis for diagnosis when X-rays are negative but high clinical suspicion

PsA is a heterogeneous disease with multiple domains (peripheral arthritis, axial disease, enthesitis, dactylitis, skin/nail psoriasis). Treatment must address all active domains. The GRAPPA 2021 and EULAR 2023 recommendations guide domain-specific therapy selection.

• MTX first-line for predominantly peripheral arthritis; added benefit for skin involvement
• IL-17 inhibitors (secukinumab, ixekizumab) offer advantage when skin disease is prominent
• TNF inhibitors effective across all domains; preferred when IBD co-exists (infliximab/adalimumab)
• IL-23 inhibitors (guselkumab, risankizumab) highly effective for skin; efficacy in axial PsA less established
• JAK inhibitors (upadacitinib, tofacitinib) for patients failing bDMARDs; review cardiovascular risk
• Assess DAPSA, PASDAS, or MDA as composite outcome measures at each visit

Gout is the most common inflammatory arthritis worldwide and highly prevalent in India. The ACR 2020 guidelines take a treat-to-target approach for serum uric acid (SUA) with a target of <6 mg/dL for most patients and <5 mg/dL for those with tophi or frequent flares.

• Allopurinol: start low (100 mg/day), titrate every 2–4 weeks to SUA target; HLA-B*5801 screening before starting in South/Southeast Asian patients
• Febuxostat: alternative when allopurinol not tolerated; monitor cardiovascular events
• Anti-inflammatory prophylaxis (colchicine 0.5 mg daily or low-dose NSAID) for ≥3–6 months after SUA reaches target
• Colchicine first-line for acute flares; oral steroids/IL-1 inhibitors for colchicine/NSAID failure
• Lifestyle: avoid red meat, organ meats, high-fructose corn syrup, alcohol (especially beer)