The 2021 American College of Rheumatology (ACR) Guideline for the Treatment of Rheumatoid Arthritis provides updated recommendations for the pharmacologic management of rheumatoid arthritis (RA). The guideline addresses the use of disease-modifying antirheumatic drugs (DMARDs), including conventional synthetic DMARDs (csDMARDs), biologic DMARDs (bDMARDs), and targeted synthetic DMARDs (tsDMARDs), as well as glucocorticoids. It also covers the use of DMARDs in high-risk populations such as those with liver disease, heart failure, lymphoproliferative disorders, previous serious infections, and nontuberculous mycobacterial lung disease. The guideline includes 44 recommendations, 7 of which are strong and 37 are conditional. Key recommendations include: 1. **DMARD-naive patients with moderate-to-high disease activity**: - Methotrexate is strongly recommended over hydroxychloroquine or sulfasalazine. - Methotrexate is conditionally recommended over leflunomide. - Methotrexate monotherapy is strongly recommended over bDMARD or tsDMARD monotherapy. - Methotrexate monotherapy is conditionally recommended over dual or triple csDMARD therapy. - Methotrexate monotherapy is conditionally recommended over methotrexate plus a TNF inhibitor. - Methotrexate monotherapy is conditionally recommended over methotrexate plus a non-TNF inhibitor bDMARD or tsDMARD. 2. **DMARD-naive patients with low disease activity**: - Hydroxychloroquine is conditionally recommended over other csDMARDs. - Sulfasalazine is conditionally recommended over methotrexate. - Methotrexate is conditionally recommended over leflunomide. 3. **Patients who have been treated with csDMARDs, excluding methotrexate, and have moderate-to-high disease activity**: - Recommendations are similar to those for DMARD-naive patients, except for bDMARDs and tsDMARDs. 4. **Treatment modification in patients not at target**: - A treat-to-target approach is strongly recommended over usual care for patients who have not been previously treated with bDMARDs or tsDMARDs. - A treat-to-target approach is conditionally recommended over usual care for patients who have had an inadequate response to bDMARDs or tsDMARDs. - A minimal initial treatment goal of low disease activity is conditionally recommended over a goal of remission. 5. **Specific patient populations**: - Recommendations are provided for patients with subcutaneous nodules, pulmonary disease, heart failure, lymphoproliferative disorder, hepatitis B infection, nonalcoholic fatty liver disease (NAFLD), persistent hypThe 2021 American College of Rheumatology (ACR) Guideline for the Treatment of Rheumatoid Arthritis provides updated recommendations for the pharmacologic management of rheumatoid arthritis (RA). The guideline addresses the use of disease-modifying antirheumatic drugs (DMARDs), including conventional synthetic DMARDs (csDMARDs), biologic DMARDs (bDMARDs), and targeted synthetic DMARDs (tsDMARDs), as well as glucocorticoids. It also covers the use of DMARDs in high-risk populations such as those with liver disease, heart failure, lymphoproliferative disorders, previous serious infections, and nontuberculous mycobacterial lung disease. The guideline includes 44 recommendations, 7 of which are strong and 37 are conditional. Key recommendations include: 1. **DMARD-naive patients with moderate-to-high disease activity**: - Methotrexate is strongly recommended over hydroxychloroquine or sulfasalazine. - Methotrexate is conditionally recommended over leflunomide. - Methotrexate monotherapy is strongly recommended over bDMARD or tsDMARD monotherapy. - Methotrexate monotherapy is conditionally recommended over dual or triple csDMARD therapy. - Methotrexate monotherapy is conditionally recommended over methotrexate plus a TNF inhibitor. - Methotrexate monotherapy is conditionally recommended over methotrexate plus a non-TNF inhibitor bDMARD or tsDMARD. 2. **DMARD-naive patients with low disease activity**: - Hydroxychloroquine is conditionally recommended over other csDMARDs. - Sulfasalazine is conditionally recommended over methotrexate. - Methotrexate is conditionally recommended over leflunomide. 3. **Patients who have been treated with csDMARDs, excluding methotrexate, and have moderate-to-high disease activity**: - Recommendations are similar to those for DMARD-naive patients, except for bDMARDs and tsDMARDs. 4. **Treatment modification in patients not at target**: - A treat-to-target approach is strongly recommended over usual care for patients who have not been previously treated with bDMARDs or tsDMARDs. - A treat-to-target approach is conditionally recommended over usual care for patients who have had an inadequate response to bDMARDs or tsDMARDs. - A minimal initial treatment goal of low disease activity is conditionally recommended over a goal of remission. 5. **Specific patient populations**: - Recommendations are provided for patients with subcutaneous nodules, pulmonary disease, heart failure, lymphoproliferative disorder, hepatitis B infection, nonalcoholic fatty liver disease (NAFLD), persistent hyp