We systematically reviewed current guidelines for managing rheumatoid arthritis (RA) to evaluate their range and nature, assess variations in their recommendations and highlight divergence in their perspectives. We searched Medline and Embase databases using the terms ‘clinical practice guidelines’ and ‘rheumatoid arthritis’ from January 2000 to January 2017 together with publications of national and international bodies. We included guidelines providing recommendations on general RA management spanning a range of treatments and published in English. We undertook narrative assessments due to the heterogeneity of the guidelines. We identified 529 articles; 22 met our inclusion criteria. They were primarily developed by rheumatologists with variable involvement of patient and other experts. Three dealt with early RA, one established RA and 18 all patients. Most guidelines recommend regular assessments based on the Outcome Measures in Rheumatology core dataset; 18 recommended the disease activity score for 28 joints. Twenty recommended targeting remission; 16 suggested low disease activity as alternative. All guidelines recommend treating active RA; 13 made recommendations for moderate disease. The 21 guidelines considering early RA all recommended starting disease modifying drugs (DMARDs) as soon as possible; methotrexate was recommended for most patients. Nineteen recommended combination DMARDs when patients failed to respond fully to monotherapy and biologics were not necessarily indicated. Twenty made recommendations about biologics invariably suggesting their use after failing conventional DMARDs, particularly methotrexate. Most did not make specific recommendations about using one class of biologics preferentially. Eight recommended tapering biologics when patients achieved sustained good responses. Five general principles transcend most guidelines: DMARDs should be started as soon as possible after the diagnosis; methotrexate is the best initial treatment; disease activity should be regularly monitored; give biologics to patients with persistently active disease who have already received methotrexate; remission or low disease activity are the preferred treatment target.

中文翻译：

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类风湿关节炎管理指南的系统评价

我们系统地回顾了当前管理类风湿性关节炎 (RA) 的指南，以评估其范围和性质，评估其建议的差异并突出其观点的分歧。从 2000 年 1 月到 2017 年 1 月，我们使用术语“临床实践指南”和“类风湿性关节炎”以及国家和国际机构的出版物搜索了 Medline 和 Embase 数据库。我们纳入了指南，提供了涵盖一系列治疗的一般 RA 管理建议，并以英文出版。由于指南的异质性，我们进行了叙述性评估。我们确定了 529 篇文章；22 符合我们的纳入标准。它们主要由风湿病学家开发，患者和其他专家参与其中。三个处理早期RA，1 名建立 RA 和 18 名所有患者。大多数指南建议基于风湿病学核心数据集的结果测量进行定期评估；18 推荐了 28 个关节的疾病活动评分。二十个推荐的靶向缓解；16 建议低疾病活动作为替代方案。所有指南都建议治疗活动性 RA；13 对中度疾病提出了建议。考虑早期 RA 的 21 条指南均建议尽快开始使用疾病缓解药物（DMARDs）；大多数患者推荐使用甲氨蝶呤。当患者对单一疗法没有完全反应且不一定需要生物制剂时，推荐了 19 种联合 DMARD。20 人提出了关于生物制剂的建议，总是建议在常规 DMARD 失败后使用它们，特别是甲氨蝶呤。大多数人没有就优先使用一类生物制剂提出具体建议。当患者获得持续的良好反应时，八种推荐逐渐减少的生物制剂。五项一般原则超越了大多数指南： DMARD 应在诊断后尽快开始；甲氨蝶呤是最好的初始治疗；应定期监测疾病活动；向已经接受甲氨蝶呤治疗的持续活动性疾病患者提供生物制剂；缓解或低疾病活动性是首选治疗目标。甲氨蝶呤是最好的初始治疗；应定期监测疾病活动；向已经接受甲氨蝶呤治疗的持续活动性疾病患者提供生物制剂；缓解或低疾病活动性是首选治疗目标。甲氨蝶呤是最好的初始治疗；应定期监测疾病活动；向已经接受甲氨蝶呤治疗的持续活动性疾病患者提供生物制剂；缓解或低疾病活动性是首选治疗目标。