To the Editor:
We have updated the Canadian Rheumatology Association (CRA) guidelines for rheumatoid arthritis (RA) with a significant addition and expansion to an existing recommendation addressing the dose reduction/tapering and discontinuation of disease-modifying antirheumatic drugs (DMARDs). New recommendations now encompass conventional synthetic, targeted synthetic, and biologic DMARDs. This update also addresses DMARD dose reduction and discontinuation in patients on multiple agents and on combination DMARD therapy, and emphasizes a more gradual and closely monitored dose reduction strategy. This update adds to our prior best practice statements and existing treatment recommendations, which are presented in the Table.
Full list of current CRA treatment recommendations for the management of rheumatoid arthritis.
We continue to house the full version of the guideline with supporting evidence via an interactive web-based platform for guideline authoring and publication (MAGICapp; https://app.magicapp.org/#/guideline/jNxw7n).1 The online version includes the full evidence-to-decision framework that summarizes the evidence, other decisional factors, and rationale for each recommendation according to Grading of Recommendations, Assessment, Development and Evaluation (GRADE) guidance.2 We also include practical information for implementation. The recommendations and statements were developed using the GRADE-ADOLOPMENT approach,3 drawing on recommendations from the Australia and New Zealand Musculoskeletal Clinical Trials Network.4
How to cite the CRA Living Guidelines for RA. When citing the guidelines, both the original journal publication,5 this current update, and the living MAGICapp guideline1 (reflecting the most recent iteration and previously published versions) should be cited. Authors may choose to also cite previous update articles.6,7
Footnotes
FUNDING
Funding for this guideline was provided by the Canadian Rheumatology Association.
COMPETING INTERESTS
AA serves as a methodologist for the MAGIC Evidence Ecosystem Foundation; this guideline uses MAGICapp (produced by the MAGIC Evidence Ecosystem Foundation) for guideline development and dissemination. JPP received funding from the CRA to provide methodological support for guideline development. PA received honoraria for advisory boards from Janssen, Sandoz, and AbbVie. HAC received grants or contracts from AstraZeneca, Fresenius Kabi, Pfizer; consulting fees from AbbVie, Amgen, AstraZeneca, Celltrion, Eli Lilly, GSK, Hoffman-La Roche, Janssen, Fresenius Kabi, Novartis, Pfizer (New York), Otsuka, Sandoz (New Jersey), Sobi; payments or honoraria for lectures, presentations, speakers bureaus, manuscript writing, or educational events from AbbVie, Amgen, AstraZeneca, BMS, Celltrion, Eli Lilly, Fresenius Kabi, GSK, Janssen, Novartis, Otsuka, Pfizer, Sobi; payments for expert testimony from Amgen; support for attending meetings and/or travel from AbbVie, Janssen, UCB, Fresenius Kabi; and participation on data safety monitoring boards or advisory boards for AbbVie, Amgen, AstraZeneca, BMS, Celltrion, Eli Lilly, Fresenius Kabi, GSK, Janssen, Novartis, Otsuka, Pfizer, and Sobi. CB received payments or honoraria for lectures, presentations, speakers bureaus, manuscript writing, or educational events from Janssen, Amgen, UCB, and Fresenius Kabi. SJ received consulting fees from AbbVie, Amgen. Celltrion. Roche, Eli Lilly, GSK, Fresenius Kabi, Pfizer, Sandoz, Sobi, UCB; payments or honoraria for lectures, presentations, speakers bureaus, manuscript writing, or educational events from AbbVie, Amgen, Celltrion, Fresenius Kabi, Pfizer, Sandoz, UCB; support for attending meetings and/or travel from Fresenius Kabi, UCB, Celltrion, AbbVie; and leadership or fiduciary roles (pain or unpaid) with the CRA Rheum Review Course (Chair), and The Journal of Rheumatology (Board of Directors). JEP received grants or contracts from BMS, Mallinckrodt/Therakos, Pfizer (Seattle Genetics); consulting fees from AbbVie, Amgen, AstraZeneca, Boehringer Ingelheim, Boxer Capital, BMS, Celltrion, Eli Lilly, Fresenius Kabi, Genzyme, GSK, Janssen, Merck, Novartis, Pfizer, Sandoz, Sanofi; payments or honoraria for lectures, presentations, speakers bureaus, manuscript writing, or educational events from AbbVie, Amgen, Boehringer Ingelheim, BMS, Certa, Eli Lilly, Fresenius Kabi, Janssen, Mallinckrodt/Therakos, Nordic, Merck, Novartis, Organon, Otsuka, Palleon, Pfizer, Roche, Sandoz, Sanofi, UCB, Zura; participation on data safety monitoring boards or advisory boards for AstraZeneca, Horizon, Novartis; and leadership or fiduciary roles (pain or unpaid) with the CRA Scientific Committee (Chair), Education, Therapeutics, Guidelines, Human Resources, LEAP (Chair), Ontario Rheumatology Association Committee for AGM (Chair), Access, Therapeutics, American College of Rheumatology (Abstract Co-Chair, Meeting and Planning Committee), RheumNow (Reporter), Around the Rheum Podcast (CRA), and TREG International Faculty. LP is managing director of the Canadian Arthritis Patient Alliance. DPR is vice president of the Canadian Arthritis Patient Alliance. JCT received consulting fees from Accord, Medexus, Nordic, Sandoz, Organon; and leadership or fiduciary roles (paid or unpaid) with the CRA, Ontario Rheumatology Association Early Arthritis Cohort, and Canadian Scleroderma Research Group. PT is an Advisory Committee member of the Reformulary Group; has other financial or nonfinancial interests in AbbVie, AstraZeneca, Aurinia, BMS, Centrexion, GSK, Horizon, Janssen, Novartis, Pfizer, Sparrow; and is chair of the Management Group, OMERACT. The remaining authors declare no conflicts of interest relevant to this article.
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