Unifying Concepts

The 2008 ACR Recommendations for Rheumatoid Arthritis Treatments

  • Initiating treatment with methotrexate or Arava (leflunomide) was recommended for most rheumatoid arthritis patients.
  • Methotrexate plus Plaquenil (hydroxychloroquine) was recommended for rheumatoid arthritis patients with moderate to high disease activity.

  • The combination of three Disease-modifying antirheumatic drugs – DMARDs – (methotrexate plus hydroxychloroquine plus sulfasalazine) was recommended for patients with moderate to high levels of disease activity and factors that suggest a poor prognosis (predicted course of the disease).
  • Treatment with a Tumor Necrosis Factor (TNF) blocker [Enbrel (etanercept), Remicade (infliximab), or Humira (adalimumab)] plus methotrexate is recommended for patients with early rheumatoid arthritis (symptoms for less than 3 months) only when there is high disease activity and the patient has never been treated with a DMARD.
  • For rheumatoid arthritis patients with moderate to long disease duration, TNF blockers were recommended for those who failed to get a satisfactory response from methotrexate therapy.
  • Orencia (abatacept) and Rituxan (rituximab) should be reserved for patients with at least moderate disease activity and a poor disease prognosis following treatment with methotrexate or other DMARDs that led to an inadequate treatment response.
  • Treatment with methotrexate, Arava, or biologic DMARDs (Enbrel, Remicade, Humira, Orencia, or Rituxan) should not be started or resumed in patients with an active bacterial infection, active herpes-zoster viral infection, active or latent tuberculosis, or acute or chronic hepatitis B or hepatitis C.
  • TNF blockers should not be prescribed to rheumatoid arthritis patients with a history of heart failure, lymphoma, mutliple sclerosis, or other demyelinating disorders.
  • Methotrexate, Arava, or minocycline should not be started or resumed for the treatment of rheumatoid arthritis in patients planning for pregnancy or throughout pregnancy and breastfeeding.

The American College of Rheumatology (ACR) expects to regularly update the recommendations as new scientific evidence becomes available. To reiterate an important point, these are only recommendations. Individual patients may require a different plan.




  1. Saag KG, Teng GG, Patkar NM, Anuntiyo J, Finney C, Curtis JR, Paulus HE, Mudano A, Pisu M, Elkins-Melton M, Outman R, Allison JJ, Suarez Almazor M, Bridges SL Jr, Chatham WW, Hochberg M, MacLean C, Mikuls T, Moreland LW, O’Dell J, Turkiewicz AM, Furst DE; American College of Rheumatology. American College of Rheumatology 2008 recommendations for the use of nonbiologic  and biologic disease-modifying antirheumatic drugs in rheumatoid arthritis. Arthritis Rheum. 2008 Jun 15;59(6):762-84. [Medline]


Created: Jul 1, 2009

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