In the June 15, 2008 issue of Arthritis Care & Research, the American College of Rheumatology (ACR) published updated guidelines on the use of nonbiologic disease-modifying anti-rheumatic drugs (DMARDs) for the treatment of rheumatoid arthritis (RA). The guidelines also provide recommendations for the use of biologic agents for the first time. The ACR recommendations are the culmination of a systematic review of evidence that updates guidelines that were previously released in 2002. They were developed for specialists who are familiar with assessing RA activity and disease severity.
Assessing DMARD Therapies 

The ACR recommendations provide evidence-based suggestions for when to initiate biologic and nonbiologic DMARDs. Recommendations should be based on the level of disease activity, duration of RA, and factors that pertain to prognosis. Nonbiologic DMARD combinations recommended in the guidelines and used most commonly include methotrexate plus hydroxycholoroquine, methotrexate plus sulfasalazine, methotrexate plus leflunomide, sulfasalazine plus hydroxychloroquine, and sulfasalazine plus hydroxychloroquine followed by methotrexate. Monotherapy with either methotrexate or leflunomide, however, is recommended as initial therapy for most patients with RA for all disease durations and degrees of disease activity.

Biologic therapies have assumed a significant role in the treatment of RA, particularly for patients with severe RA and high disease activity after failure of nonbiologic DMARDs. The updated guidelines recommend appropriate times to consider biologics and provide safety considerations that should be recognized when using these therapies. Biologic DMARDs are separated according to disease duration (less than 6 months and 6 months or longer). Patients with early RA and only low or moderate disease activity are not considered candidates for biologic therapy. Anti-TNF