San Francisco, CA—New recommendations from the American College of Rheumatology (ACR) for the treatment of rheumatoid arthritis (RA) were presented at the ACR annual meeting and published simultaneously online in Arthritis & Rheumatology and Arthritis Care & Research. The new recommendations address such challenges as the treat-to-target strategy and when to taper or discontinue treatment, but avoid discussion of biosimilars.
Biosimilars are important to patients with RA because their cost may be lower. But the panel believed there was not enough evidence to make recommendations, especially because no biosimilars for RA have been approved to date by the US Food and Drug Administration.
In contrast with the 2012 RA recommendations, the 2015 guidelines were developed using a different methodology.
“We used the GRADE methodology (Grading of Recommendations Assessment, Development, and Evaluation), because it is an internationally accepted systematic approach to guideline development. Important features of the GRADE method include the clear specification of patient groups, interventions, competing alternative treatments, and outcomes, providing a grade for the quality of evidence used and basing recommendation strength on evidence quality, balancing the benefits and harms, patient preferences, and clinical experience and expertise,” said panel member Jasvinder A. Singh, MD, of the University of Alabama at Birmingham. Dr Singh discussed the new guidelines at a formal press conference.
In contrast with the 2012 guidelines, the new guidelines strongly recommend the treat-to-target approach, with specific goals of low disease activity and remission.
Also new is the inclusion of separate algorithms for symptomatic early RA and established RA based on disease duration of <6 months or >6 months. For both groups, the initial recommendation is to start with a treat-to-target strategy. For early disease, patients who are naive to disease-modifying antirheumatic drugs (DMARDs) should start with a DMARD, preferably methotrexate.
Also new is guidance on switching therapy and tapering therapy.
The panel addressed the treatment of high-risk patients, such as those with RA plus hepatitis B, hepatitis C, or skin cancer. There is little evidence on the best course of treatment for these patients, and the panel had difficulty coming up with a universal consensus. They eventually decided on initiating therapy with conventional DMARDs—not biologics.
Tofacitinib and glucocorticoids are also addressed in the 2015 guidelines. Other important issues that have been included are use of vaccines in patients taking DMARDs, advice on screening for tuberculosis in patients on biologics or tofacitinib, and recommendations for laboratory monitoring of patients on DMARDs.
Singh JA, Saag KG, Bridges SL Jr, et al. 2015 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Rheumatol. 2015 Nov 6. Epub ahead of print.