Table 1.
Indications for Initiating and Switching Nonbiologic and Biologic DMARDs
Disease Activity
Early RA (< 6 mo)
Established RA (=6 mo or meets
1987 ACR RA classification criteria)
If prognosis is not mentioned,
use or switch to a nonbiologic
or biologic DMARD regardless
of prognostic features
ACR = American College of Rheumatology; CCP = cyclic citrullinated peptide; DMARD = disease-modifying
antirheumatic drug; MTX = methotrexate; RA = rheumatoid arthritis; RF = rheumatoid factor; TNF = tumor
Recommendation
Administer DMARD combination therapy (eg, double or triple
therapy) in those with moderate or high disease activity and poor
prognostic features (functional limitation, extra-articular disease,
positive RF or anti-CCP antibodies, bony erosions on x-ray)
Use an anti-TNF agent MTX in those with high disease activity and
poor prognostic featuresexcept for infliximab, which is used in
combination with MTX only (ie, do not use infliximab as
monotherapy)
Initiating and switching among nonbiologic DMARDs
In patients without prognostic features who deteriorate after 3 mo of
DMARD monotherapy from low to moderate/high disease activity, add
MTX, hydroxycholoroquine, or leflunomide
In patients with persistent moderate/high disease activity after 3 mo of
MTX or MTX-DMARD combination therapy, either add or switch to
another non-MTX DMARD
Switching from nonbiologic to biologic DMARDs
Alternatively, in patients with persistent moderate/high disease activity
after 3 mo of MTX monotherapy or MTX-DMARD combination
therapy, add or switch to an anti-TNF biologic agent, abatacept, or
rituximab
In patients with persistent moderate/high disease activity after 3 mo of
intensified DMARD combination therapy or after a second DMARD,
add or switch to an anti-TNF biologic agent
Switching among biologic agents because of lack or loss of benefit
In patients with persistent moderate/high disease activity after 3 mo of
anti-TNF biologic therapy because of lack or loss of treatment benefit,
switch to another anti-TNF biologic agent or a non-TNF biologic agent
In patients with persistent moderate/high disease activity after 6 mo of
non-TNF biologic therapy because of lack or loss of treatment benefit,
switch to another non-TNF biologic agent or an anti-TNF biologic
agent
Switching among biologic agents because of adverse effects
In patients with high disease activity after failure of anti-TNF biologic
therapy because of a serious adverse event, switch to a non-TNF
biologic agent
In patients with moderate or high disease activity after failure of anti-
TNF biologic therapy because of a nonserious adverse event, switch to
another anti-TNF biologic agent or a non-TNF biologic agent
In patients with moderate or high disease activity after failure of non-
TNF biologic therapy because of either a serious or a nonserious
adverse event, switch to another non-TNF biologic agent or an anti-
TNF biologic agent
necrosis factor.

Source: Singh JA, Furst DE, Bharat A, et al. 2012 update of the 2008 American College of Rheumatology
recommendations for the use of disease-modifying antirheumatic drugs and biologic agents in the treatment of
rheumatoid arthritis. Arthritis Care Res (Hoboken). 2012 May;64(5):625-39.

Table 2. 2012 ACR Recommendations for Further Evaluation After Initial/Repeat TB Screening
Results
Result of
Initial/Repeat TST Recommendation
or IGRA
Positive Obtain chest x-ray
If the chest x-ray is suspicious for active TB, obtain sputum examination for active
disease
Negative In patients with RA but without risk factors or clinical suspicion for TB

No further workup is needed

In patients with RA and immunosuppression plus LTBI risk factors

LBTI is not excluded

Repeat the TST or IGRA 1-3 wk after an initial negative test result
Active/latent TB Treat with appropriate antitubercular therapy
Refer to a specialist as necessary
Initiate or resume biologic agents after either 1 mo of treatment of LTBI with
antitubercular regimen or completion of treatment for active TB
Screen annually in individuals with RA who (1) are continuing on biologic agents while
living, traveling, or working in situations of likely TB exposure and (2) have a positive
baseline for TST or IGRA; TST or IGRA may still be positive after successful TB
therapy; monitor for clinical signs or symptoms of recurrent TB
ACR = American College of Rheumatology; IGRA = interferon gamma release assay; LBTI = latent tuberculosis
infection; RA = rheumatoid arthritis; TB = tuberculosis; TST = tuberculin skin test.

Source: Singh JA, Furst DE, Bharat A, et al. 2012 update of the 2008 American College of Rheumatology
recommendations for the use of disease-modifying antirheumatic drugs and biologic agents in the treatment of
rheumatoid arthritis. Arthritis Care Res (Hoboken). 2012 May;64(5):625-39.[67]