Treatment of Rheumatoid Arthritis: American College of Rheumatology Guidelines 2021
The American College of Rheumatology has updated guidelines for the pharmacologic management of rheumatoid arthritis. The recommendations have been elaborated in the journal Arthritis Care & Research.
An expert panel from the American College of Rheumatology developed clinically relevant population, intervention, comparator, and outcomes (PICO) questions. After conducting a systematic literature review, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to rate the certainty of evidence. A voting panel comprising clinicians and patients achieved consensus on the direction (for or against) and strength (strong or conditional) of recommendations.
The guideline addresses treatment with disease-modifying antirheumatic drugs (DMARDs), including conventional synthetic DMARDs, biologic DMARDs, and targeted synthetic DMARDs, use of glucocorticoids, and use of DMARDs in certain high-risk populations (i.e., those with liver disease, heart failure, lymphoproliferative disorders, previous serious infections, and nontuberculous mycobacterial lung disease). The guideline includes 44 recommendations (7 strong and 37 conditional).
Recommendations for DMARD-naive patients with moderate-to-high disease activity
Initiation of treatment in DMARD-naive patients with moderate-to-high disease activity Methotrexate monotherapy is strongly recommended over: Hydroxychloroquine or sulfasalazine/DMARD or tsDMARD monotherapy
Combination of methotrexate plus a non–TNF inhibitor bDMARD or tsDMARD Methotrexate monotherapy is conditionally recommended over: Leflunomide Dual or triple csDMARD therapy/ Combination of methotrexate plus a TNF inhibitor.
Initiation of a csDMARD without short-term (<3 months) glucocorticoids is conditionally recommended over initiation of a csDMARD with short-term glucocorticoids. Very lowInitiation of a csDMARD without longer-term (≥3 months) glucocorticoids is strongly recommended over initiation of a csDMARD with longer-term glucocorticoids.Moderate
Initiation of treatment in DMARD-naive patients with low disease activity
Hydroxychloroquine is conditionally recommended over other csDMARDs. Very low
Sulfasalazine is conditionally recommended over methotrexate. Very low
Methotrexate is conditionally recommended over leflunomide. Very low
Initiation of treatment in csDMARD-treated, but methotrexate-naive, patients with moderate-to-high disease activity
Methotrexate monotherapy is conditionally recommended over the combination of methotrexate plus a bDMARD or tsDMARD.**
· Oral methotrexate is conditionally recommended over subcutaneous methotrexate for patients initiating methotrexate
· Initiation/titration of methotrexate to a weekly dose of at least 15 mg within 4 to 6 weeks is conditionally recommended over initiation/titration to a weekly dose of <15 mg
· A split dose of oral methotrexate over 24 hours or weekly subcutaneous injections, and/or an increased dose of folic/folinic acid, is conditionally recommended over switching to alternative DMARD(s) for patients not tolerating oral weekly methotrexate
· Switching to subcutaneous methotrexate is conditionally recommended over the addition of/switching to alternative DMARD(s) for patients taking oral methotrexate who are not at target
Treat-to-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
· Addition of a bDMARD or tsDMARD is conditionally recommended over triple therapy (i.e., addition of sulfasalazine and hydroxychloroquine) for patients taking maximally tolerated doses of methotrexate who are not at target
· Switching to a bDMARD or tsDMARD of a different class is conditionally recommended over switching to a bDMARD or tsDMARD belonging to the same class for patients taking a bDMARD or tsDMARD who are not at target
Use of glucocorticoids
· Addition of/switching to DMARDs is conditionally recommended over continuation of glucocorticoids for patients taking glucocorticoids to remain at target
· Addition of/switching to DMARDs (with or without intraarticular [IA] glucocorticoids) is conditionally recommended over the use of IA glucocorticoids alone for patients taking DMARDs who are not at target
Recommendations for tapering/discontinuing DMARDs
· Continuation of all DMARDs at their current dose is conditionally recommended over a dose reduction of a DMARD, dose reduction is conditionally recommended over gradual discontinuation of a DMARD, and gradual discontinuation is conditionally recommended over abrupt discontinuation of a DMARD for patients who are at target for at least 6 months
· Gradual discontinuation of sulfasalazine is conditionally recommended over gradual discontinuation of hydroxychloroquine for patients taking triple therapy who wish to discontinue a DMARD
· Gradual discontinuation of methotrexate is conditionally recommended over gradual discontinuation of the bDMARD or tsDMARD for patients taking methotrexate plus a bDMARD or tsDMARD who wish to discontinue a DMARD
Recommendations for specific patient populations
· Subcutaneous nodules
Methotrexate is conditionally recommended over alternative DMARDs for patients with subcutaneous nodules who have moderate-to-high disease activity
Switching to a non-methotrexate DMARD is conditionally recommended over continuation of methotrexate for patients taking methotrexate with progressive subcutaneous nodules
· Pulmonary disease
Methotrexate is conditionally recommended over alternative DMARDs for the treatment of inflammatory arthritis for patients with clinically diagnosed mild and stable airway or parenchymal lung disease, or incidental disease detected on imaging, who have moderate-to-high disease activity
· Heart failure
Addition of a non–TNF inhibitor bDMARD or tsDMARD is conditionally recommended over addition of a TNF inhibitor for patients with New York Heart Association (NYHA) class III or IV heart failure and an inadequate response to csDMARDs
Switching to a non–TNF inhibitor bDMARD or tsDMARD is conditionally recommended over continuation of a TNF inhibitor for patients taking a TNF inhibitor who develop heart failure
· Lymphoproliferative disorder
Rituximab is conditionally recommended over other DMARDs for patients who have a previous lymphoproliferative disorder for which rituximab is an approved treatment and who have moderate-to-high disease activity.
"This clinical practice guideline is intended to serve as a tool to support clinician and patient decision-making. Recommendations are not prescriptive, and individual treatment decisions should be made through a shared decision-making process based on patients' values, goals, preferences, and comorbidities."the expert team opined.
For full article, follow the link: https://doi.org/10.1002/acr.24596
Source : Arthritis Care & Research
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