Rheumatology

2025 EULAR RA update sharpens MTX-first strategy and JAK inhibitor safety positioning

The 2025 EULAR recommendations reaffirm methotrexate, ideally with short-term glucocorticoids, as preferred initial RA csDMARD therapy. If treatment targets are not reached within 3–6 months, addition of a bDMARD is recommended, with JAK inhibitors considered only after careful risk assessment. The task force explicitly weighs JAK inhibitor risks, including MACEs, malignancy, and thromboembolic events, against bDMARD alternatives. Guidance addresses monotherapy versus combination therapy, treat-to-target strategies, sequencing after b/tsDMARD failure, and tapering in sustained remission. They caution that full DMARD discontinuation frequently triggers flare, supporting gradual, individualized tapering rather than stopping. 1

Targeted DMARDs generally stabilise lung function in RA-associated interstitial lung disease

This systematic review and meta-analysis pooled 18 observational studies including 958 patients with RA-associated ILD. Overall, forced vital capacity and DLCO showed no significant change over follow-up, suggesting pulmonary function stabilisation with b/tsDMARDs. Data spanned rituximab, abatacept, JAK inhibitors, TNF inhibitors, and tocilizumab, without clear between-agent differences in lung function trajectories. Usual and nonspecific interstitial pneumonia patterns predominated, mirroring typical RA-ILD seen clinically. Findings support using targeted therapies when needed for RA control in RA-ILD, while emphasising the need for prospective HRCT-integrated studies. 2

JAK inhibitors and abatacept signal increased keratinocyte cancer risk versus TNF inhibitors

This Swedish nationwide cohort of 21,756 RA patients compared keratinocyte cancer risk across JAK inhibitors, TNF inhibitors, and non-TNF biologics. JAK inhibitors carried a higher incident keratinocyte cancer risk versus TNF inhibitors, with an adjusted hazard ratio of 1.39. Both basal cell and squamous cell carcinoma risks were elevated with JAK inhibitors compared with TNF inhibitors. Non-TNF biologics as a class were not associated with increased keratinocyte cancer, but abatacept showed higher squamous cell carcinoma risk versus etanercept. Risk of second primary keratinocyte cancers was numerically higher with JAK inhibitors but not clearly increased with non-TNF biologics. 3