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Figure 3 | Trials

Figure 3

From: Impact of a magnetic resonance imaging-guided treat-to-target strategy on disease activity and progression in patients with rheumatoid arthritis (the IMAGINE-RA trial): study protocol for a randomized controlled trial

Figure 3

Treatment algorithm. Step 1: DMARD monotherapy at less than the maximum tolerated dose (maximum dose: up to MTX 25 mg/week, SSZ 3 g/day, HCQ 400 mg/day or LEF 20 mg/day). Step 2: DMARD monotherapy at the maximum tolerated dose (maximum dose: up to MTX 25 mg/week, SSZ 3 g/day, HCQ 400 mg/day or LEF 20 mg/day. Minimum dose: min. MTX 7.5 mg/week, SSZ 1 g/day, HCQ 200 mg/day, LEF 10 mg/day). Step 2a: DMARD combination therapy at less that the maximum tolerated doses (maximum dose up to MTX 25 mg/week, SSZ 2 g/day and HCQ 200 mg/day). Step 3: DMARD combination therapy at the maximum tolerated doses (maximum dose up to MTX 25 mg/week, SSZ 3 g/day and HCQ 400 mg/day). Step 3a: LEF (in case of adverse reactions or intolerance to two of the following: MTX, SSZ, HCQ in three-drug therapy, change to monotherapy LEF 20 mg/day without prior loading dose). Step 4: MTX or LEF or SSZ (prioritized sequence) at the maximum tolerated dose + adalimumab* Step 5: MTX or LEF or SSZ (prioritized sequence) at the maximum tolerated dose + other TNF-alpha inhibitor* (selected by the attending rheumatologist). Steps 6, 7 and 8: MTX or LEF or SSZ (prioritized sequence) at the maximum tolerated dose + biological treatment* (preferably non-TNF-alpha inhibitor). *Biological treatment is administered in combination with DMARD monotherapy treatment in the following prioritized order: MTX, LEF, SSZ. If the patient develops adverse reactions to the supplemented DMARD monotherapy treatment and is unable to tolerate the minimum dose, a switch must be made to another DMARD in the mentioned prioritized order.

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