EULAR: What’s new in 2024?

The European Alliance of Associations for Rheumatology (EULAR) – the European umbrella organisation representing scientific societies, health professional associations, and organisations for people with rheumatic and musculoskeletal diseases (RMDs) – aims to reduce the burden of these conditions, as well as improve RMD treatments, prevention, and rehabilitation across Europe. The alliance has updated several of its recommendations and guidance in response to emerging data and novel treatment strategies over recent months.

Latest update for psoriatic arthritis

To incorporate novel agents and classes, EULAR has updated its recommendations on the pharmacological management of psoriatic arthritis (PsA). It is estimated that up to 30,000 people in Ireland suffer from the autoimmune inflammatory disease, which is commonly associated with psoriasis, and has been linked to cardiovascular, psychological, and metabolic comorbidities, as well as a significant impact on quality-of-life.

EULAR anticipates that the practical and updated guidance will be useful to both healthcare professionals and their patients, and support access to optimal care for people with PsA.

The EULAR recommendations for pharmacological management in PsA were first written in 2012, and updated in 2015 and 2019. Since then, novel agents with new mechanisms have become available, alongside an array of new long-term data for existing drugs. The latest recommendations include seven overarching principles, three of which remain unchanged from the last publication, and three which have been reworded.

The single new principle states that the choice of treatment should take into account safety considerations regarding individual modes of action in order to optimise the benefit-risk profile. There are also 11 individual recommendations; four remain unchanged, six are modified, merged, or reworded, and one is new.

According to the recommendations, non-steroidal anti-inflammatory drugs (NSAIDs) can be proposed as first-line treatment but should not be given alone if there are signs the disease may be severe. In people with peripheral arthritis, which encompasses the vast majority of people with the disease, a quick start of conventional synthetic disease modifying antirheumatic drugs (DMARDs) is recommended, with a preference for methotrexate. If this strategy fails, then a biological DMARD (bDMARDs) should be started. No preferred class of drug is recommended.

EULAR also proposes the use of Janus kinase inhibitors (JAKi) after bDMARD failure, or where bDMARDs are not appropriate for the individual patient. Apremlast can be proposed in some specific cases, and the revised document includes an algorithm for treatment of patients with predominantly axial or entheseal disease.

Conventional synthetic DMARDs are not used for these patients. Axial disease responds well to tumour necrosis factor inhibitors (TNFi) or interleukin (IL)-17 inhibitors. The mode of action chosen should reflect non-musculoskeletal manifestations, with specific recommendations for people with skin, gut, or eye involvement. For example, in people with skin psoriasis, treatment should be directed to bDMARDs that target ILs, and there are now four classes to choose from: IL-12/23, IL-23p19, IL-17A, and IL-17A/ F inhibitors.

People with uveitis should receive a monoclonal TNFi, according to the revised recommendations, and people with inflammatory bowel disease should be prescribed a drug authorised for this disease (TNFi, IL-12/23 inhibitor, JAKi, in some cases IL-23 inhibitor). As well as treatment recommendations, the publication also addresses topics such as drug switches and tapering for patients in sustained remission.

Points to consider in hyperinflammation

EULAR has worked in partnership with the American College of Rheumatology (ACR) to develop a set of new points-to-consider for two life-threatening syndromes that can develop in people with inflammatory diseases, specifically haemophagocytic lymphohistiocytosis (HLH) and macrophage activation syndrome (MAS). Although systemic hyperinflammation and HLH/MAS can occur in a variety of inflammatory states, there are certain predisposing conditions and inflammatory triggers, including rheumatic diseases, malignancies, metabolic diseases, and genetic immune problems.

HLH and MAS lead to multiple organ dysfunction and failure, and are often fatal diagnoses. Both are characterised by fever, increased systemic and central nervous system inflammation, low blood cell count, coagulopathy, and hepatitis. HLH and MAS can progress rapidly, therefore, early identification and management are crucial to achieving optimal patient outcomes. However, identifying at-risk patients can be challenging for clinicians.

To support this, EULAR has developed new evidence and consensus-based points-to-consider to support clinicians in the diagnosis, treatment, and monitoring of HLH/MAS.  The major, unexplained, or unusually severe clinical and laboratory features, particularly if co-occurring, that may represent a systemic hyperinflammatory syndrome and should prompt consideration of HLH/MAS in appropriate clinical contexts are outlined in Table 1.

The document was completed by an expert taskforce of adult and paediatric rheumatologists, haematologists, oncologists, immunologists, infectious disease specialists, intensivists, and allied healthcare professionals, as well as patients and their families. The resulting paper, which was published in the Annals of Rheumatic Disease and simultaneously in Arthritis and Rheumatology, includes six overarching statements and 24 specific points-to-consider in total.

Major themes include the need for prompt syndrome recognition and systematic evaluation of underlying contributors, alongside early intervention that targets both the hyperinflammation and its likely contributors.

The authors also stress the need for careful monitoring of progression and complications, as well as the importance of expert multidisciplinary assistance and collaboration. A helpful flowchart is provided to outline the key stages of assessment, investigation, and treatment of people with hyperinflammation and suspected HLH/MAS (Figure 1).

Updated: Hip and knee osteoarthritis

Non-drug recommendations for people with hip or knee osteoarthritis (OA) have been updated by EULAR. OA is the most prevalent joint disease globally, and although treatment options have evolved, there is a distinct lack of disease-modifying drugs and no cure for the debilitating condition. Instead, the core management encompasses non-pharmacological strategies to help people manage their pain and maintain or increase their physical function, therefore, EULAR has updated its recommendations on the core management of hip and knee OA with non-pharmacological strategies.

The last EULAR recommendations for non-pharmacological management of people with hip or knee OA were published in 2013. The updated recommendations were developed by a multidisciplinary taskforce in response to the research findings that have since been published. An individualised, holistic, patient-centred approach is a core element of the recommendations.

A prominent change from the old document is that two previous statements have been rephrased into overarching principles and some new aspects regarding digital delivery of services have been added, along with an increased focus on the importance of combining treatments tailored to the needs of the individual patient. In total, there are two overarching principles and eight recommendations.

The principles state that people with hip or knee OA should have an initial assessment using a biopsychosocial approach that considers their physical and psychological status, as well as each person’s activities of daily living participation, including work, social determinants, and environmental factors. The authors also stress that treatment choices should be based on shared decision-making that considers the needs, preferences, and capabilities of each individual person.

The individual recommendations go on to consider education, exercise, and weight loss, as well as self-management strategies and workplace adjustments. EULAR hopes the updated recommendations will be implemented across Europe, and will help to improve the situation for many people with OA. However, the alliance also stresses that there are a number of cur  VVrent evidence gaps, and included a proposed research agenda on key aspects. EULAR also recommends several educational initiatives to help increase knowledge about hip and knee OA, both for healthcare professionals, and for people living with the disease.