Guideline released on rheumatoid arthritis treatment

The American College of Rheumatology released a new guideline last week on pharmacologic treatment for rheumatoid arthritis (RA).

The guideline, which was based on a systematic review of the literature, covers treatment of patients with early RA, defined as a disease duration of less than 6 months; treatment of patients with established RA; laboratory monitoring for disease-modifying antirheumatic drugs (DMARDs); treatment of patients with RA and high-risk comorbid conditions, such as congestive heart failure and hepatitis B; and use of vaccines in patients taking DMARDs and/or biologic therapy.

The guideline panel recommended a treat-to-target approach rather than a nontargeted approach in patients with early symptomatic RA and those with established RA, regardless of disease activity.

Some of the other key recommendations for patients with early symptomatic RA are as follows:

• For DMARD-naive patients, the panel strongly recommends DMARD monotherapy over double or triple DMARD therapy in patients with low disease activity and conditionally recommends DMARD monotherapy over double or triple DMARD therapy in patients with moderate or high disease activity. Methotrexate should be the preferred initial therapy for most patients with early RA and active disease.
• For patients with moderate or high disease activity despite DMARD therapy (with or without glucocorticoids), the panel strongly recommends treatment with a combination of DMARDs or a tumor necrosis factor (TNF) inhibitor or a non-TNF biologic, with or without methotrexate in no particular order of preference, rather than continuing DMARD monotherapy alone. The panel noted that biologic therapy should be used in combination with methotrexate over biologic monotherapy, when possible, due to superior efficacy.
• For patients with moderate or high disease activity despite any of the previously described DMARD or biologic therapies, the panel conditionally recommends adding low-dose glucocorticoids (defined as ≤10 mg of prednisone daily or equivalent). The panel noted that low-dose glucocorticoids may also be used in patients who need a bridge until beginning to benefit from DMARD therapy. The panel said that glucocorticoids have a favorable risk/benefit ratio if the dose is low and the duration of therapy is short.

Some of the other key recommendations in patients with established RA are as follows:

• For DMARD-naive patients with low disease activity, the panel strongly recommends DMARD monotherapy over a TNF inhibitor. For DMARD-naive patients with moderate or high disease activity, the panel conditionally recommends DMARD monotherapy over double or triple DMARD therapy and DMARD monotherapy over tofacitinib. Methotrexate should generally be the preferred initial therapy for most patients with established RA with active disease, the panel said.
• For patients with moderate or high disease activity despite DMARD monotherapy including methotrexate, the panel strongly recommends combination DMARDs or adding a TNF inhibitor or a non-TNF biologic or tofacitinib (all choices with or without methotrexate) in no particular order of preference, rather than continuing DMARD monotherapy. Biologic therapy should be used in combination with methotrexate over biologic monotherapy, when possible, due to its superior efficacy.
• The panel strongly recommends not discontinuing all therapies in patients with established RA that is in disease remission.

The recommendations differ from previous American College of Rheumatology guidelines on RA because they are based only on disease activity rather than on both disease activity and prognosis, the panel wrote. They also noted that the field is rapidly changing and that some of their recommendations may soon be outdated. Use of nonpharmacologic interventions and use of DMARDs and biologic agents in patients with less common comorbid conditions were not addressed, and recommendations were made for categories of drugs rather than specific agents, they said.

Future research should examine biologic agents and DMARDs during conception, pregnancy, and breastfeeding; RA treatment in patients with interstitial lung disease; laboratory monitoring for biologic agents and tofacitinib; and biomarker testing, the panel wrote. They stressed that the guideline should be considered “a useful tool not only to guide treatment in clinical practice but also to facilitate discussion about individualized treatment decision-making between patients and their clinicians.”

The complete guideline, which includes treatment algorithms, is available free of charge online.