Interpretation of the "2024 Chinese Guidelines for the Diagnosis and Treatment of Rheumatoid Arthritis"

Source: Peking Union Medical College Hospital

Author: Jiang Nan, Tian Xinping, Li Mengtao, Zeng Xiaofeng

Rheumatoid arthritis (RA) is a systemic autoimmune disease with chronic erosive arthritis as the main clinical manifestation. The disease has a high disability rate, and the probability of patients developing complications such as cardiovascular and cerebrovascular diseases and osteoporosis is significantly higher than that of the general population. However, the diagnosis and treatment of this disease still has the current status and problems such as low early diagnosis rate, missed diagnosis and misdiagnosis.

Initiated by the National Clinical Research Center for Skin and Immunological Diseases, in collaboration with academic institutions such as the Rheumatology and Immunology Specialists Branch of the Chinese Medical Association, the "2024 China Rheumatoid Arthritis Diagnosis and Treatment Guidelines" were revised and released, providing evidence-based recommendations for the 10 major clinical issues of concern to rheumatologists in my country.

Authors of this article: Jiang Nan (1st from left), Tian Xinping (2nd from left), Li Mengtao (3rd from left), Zeng Xiaofeng (right) from Peking Union Medical College Hospital

The diagnosis of rheumatoid arthritis should take into account clinical manifestations, imaging examinations and other results

Early diagnosis of rheumatoid arthritis plays an important role in improving the prognosis of patients. When making a diagnosis of patients suspected of RA, their clinical manifestations, laboratory tests and imaging examination results should be comprehensively considered. The internationally recognized RA classification standards can be used as an important reference for diagnosis. The classification standards issued by the American College of Rheumatology (ACR) in 1987 and the classification standards issued by ACR/European League Against Rheumatism (EULAR) in 2010 are currently the most widely recognized and widely used RA classification standards internationally. In view of my country's national conditions, the guidelines recommend that both classification standards can be used as references for RA diagnosis. It should be emphasized that the classification standards are not diagnostic standards, let alone gold standards. Clinicians need to make comprehensive judgments based on the specific conditions of the patients when making diagnoses.

Imaging examinations are an effective means for clinicians to diagnose and evaluate RA. In particular, musculoskeletal ultrasound and magnetic resonance imaging (MRI) have played an increasingly important role in the early diagnosis of RA, assessment of joint lesions, and recurrence monitoring in recent years. The 2024 version of the guidelines has updated the relevant content.

The treatment principle of rheumatoid arthritis is standardized treatment and regular monitoring and follow-up

Early, standardized treatment and regular monitoring and follow-up are internationally recognized principles for the treatment of RA. Achieving disease remission or low disease activity is also a recognized goal of RA treatment in international guidelines. The new guidelines once again emphasize the treatment goals of RA and update the new Boolean remission criteria launched by ACR and EULAR in 2023. Compared with the original Boolean remission criteria launched in 2011, the main update of the Boolean 2.0 standard is: changing the patient's overall evaluation threshold of the disease from "≤1" to "≤2" to avoid inaccurate disease activity assessment and overtreatment due to patients overestimating the severity of the disease.

RA patients need regular follow-up to assess disease activity and the effectiveness of drug treatment. The new guidelines emphasize the frequency of follow-up monitoring of RA patients. The guidelines comprehensively consider evidence-based medicine, patient convenience and economy, as well as the imbalance of rheumatology specialist medical resources in different regions. For RA patients who are receiving initial treatment or whose treatment does not meet the target, it is recommended to assess disease activity once every 1 to 3 months; for those who have met the treatment target, the frequency can be adjusted to once every 3 to 6 months.

The factors that need to be considered when choosing a treatment plan mainly include disease activity, poor prognostic factors, extra-articular involvement, and important complications.

Methotrexate is recommended as first-line treatment for rheumatoid arthritis

At present, methotrexate (MTX) is still the internationally recognized drug of choice for the initial treatment of RA, but its usage rate and dosage in my country are both low. The new version of the guidelines once again emphasizes the "anchor drug" status of MTX and recommends its dosage. For patients who have contraindications to or cannot tolerate MTX, the guidelines recommend the use of leflunomide or sulfasalazine.

In the application of biological disease-modifying antirheumatic drugs (bDMARDs) or targeted synthetic drugs (DMARDs), based on current evidence, comprehensive consideration of drug efficacy, adverse reactions, economy, and ease of use, and combined with the experience of rheumatologists in my country, the new version of the guidelines still recommends MTX as the preferred csDMARDs as the first-line treatment for RA patients in my country.

At present, glucocorticoids are still an important drug for the treatment of RA. Their effects of relieving symptoms and improving physical functions have been confirmed by a large number of studies. However, this drug may increase the risk of various complications such as infection, cardiovascular and cerebrovascular diseases. The new version of the guidelines emphasizes that glucocorticoids can only be used in the short term and in small doses during the initial treatment of csDMARDs or when changing the csDMARDs regimen. Clinicians can choose according to the specific conditions of the patient, such as disease activity. At the same time, the new version of the guidelines explains the dosage and course of treatment of glucocorticoids, and clearly does not recommend their single use, long-term use or high-dose use.

The original article comes from the January 2025 issue of Peking Union Medical College Journal, Interpretation of the 2024 Chinese Guidelines for the Diagnosis and Treatment of Rheumatoid Arthritis