Three new consensus documents from the ACR address critical issues in patient care: management of lupus nephritis (LN); using disease-modifying antirheumatic drugs (DMARDs) and biologics in the treatment of rheumatoid arthritis (RA); and selecting RA disease activity measures for use in clinical practice. Development of these documents was based on systematic literature review and the input of expert panels that reached consensus on the best recommendations for clinical decision making.
The previous ACR guidelines for management of systemic lupus erythematosus (SLE) were issued in 1999 and did not solely focus on LN.1 This year’s document, developed by a 15-member panel of experts from nephrology and rheumatology, is the first ACR guideline dedicated to LN and provides detailed recommendations for screening and treatment, including mycophenolate mofetil (MMF) therapy. The recommendations cover most of the histologic types of LN, according to Bevra Hahn, MD, professor of medicine and chief of rheumatology at the David Geffen School of Medicine at the University of California, Los Angeles. Dr. Hahn was chair of the guideline development committee and first author of the document.
An update of the ACR’s 2008 RA guidelines was needed, given the availability of new agents and new vaccines, according to Jasvinder Singh, MBBS, MPH, associate professor of medicine in the division of clinical immunology and rheumatology at the University of Alabama at Birmingham, and first author of the document.2 The new recommendations reflect the rapid pace of change within rheumatology, and they are designed to update guidance on indications for DMARDs and biologic agents, switching between DMARDs and biologic therapies, use of biologic agents in high-risk patients, and screening for tuberculosis for patients treated with biologics or DMARDs.
[The lupus nephritis guidelines are] careful to say that nothing is contraindicated, because a physician providing direct care is in the best position to decide what therapies should be initiated, modified, or discontinued.
—Bevra Hahn, MD
A third document, with recommendations for the RA disease activity measures most valid for use in clinical practice, is the first of its kind for the ACR. The goal of the working group was to determine which of the many available measures reliably distinguish between disease activity levels in RA and are feasible for clinical practice. From the 63 tools that were identified, the committee trimmed the list to six recommended measures that are sensitive to change; accurately reflect disease activity; discriminate well between low, moderate, and high disease activity states; and include remission criteria, according to Salahuddin Kazi, MD, chief health informatics officer at the Dallas VA Medical Center and a member of the development committee and senior author of the document.
Management of Lupus Nephritis
Many of the questions that practicing physicians may have about managing LN are addressed in the American College Of Rheumatology Guidelines for Screening, Treatment, and Management of Lupus Nephritis, Dr. Hahn says.3 The guidelines cover most of the histologic types of LN and are based on recent high-quality studies. “Where not based on high-quality studies, they are based on expert opinion as influenced by other studies,” she explains.