Two expert panels developed the recommendations. A nonvoting working group and core expert panel of clinicians and methodologists selected the topic areas, conducted the literature review, synthesized the evidence, and created clinical scenarios that represented the spectrum of care to be addressed by the guideline. A task force panel of 11 internationally recognized expert clinicians, patient representatives, and methodologists with expertise in RA treatment rated the scenarios and provided formal input about recommendations.
[The RA treatment recommendations] provide guidance for practitioners who will still make individual decisions with their patients depending on their patients’ preferences and risk factors and other disease factors.
—Jasvinder Singh, MBBS, MPH
Most important in these recommendations is the specific guidance about when to start, resume, add, or switch DMARD therapy or biologic agents, and how to switch between various biologic agents, says Dr. Singh. The updated recommendations also provide guidance on using biologic agents when the patient has a diagnosis of hepatitis, malignancy, or congestive heart failure. Other key points included in the document:
- Tuberculosis (TB) screening to identify latent TB infection should be done in all patients with RA who are being considered for therapy with biologic agents, regardless of the presence of risk factors for latent TB.
- Specific recommendations for vaccinations, including the pneumococcal, influenza, hepatitis B, human papillomavirus, and herpes zoster vaccines, are given for patients starting or currently receiving DMARDs or biologic agents.
- New biologics launched since the 2008 recommendations—tocilizumab, certolizumab pegol, and golimumab—are included in the treatment algorithm.
More aggressive treatment is advised for patients with early RA in this document compared with the 2008 recommendations. This type of recommendation is given due to an expectation that earlier treatment can lead to better outcomes, that prevention of joint damage is an important goal, and that early intensive therapy can help preserve physical function and improve quality of life. Dr. Singh notes that the illustrative figures included in the 2012 recommendations can provide the practitioner with “more elaborative information than that achieved in the text itself,” with details given about treatment regimens and switching between therapies. We “provide guidance for practitioners who will still make individual decisions with their patients depending on their patients’ preferences and risk factors and other disease factors that may make them choose one medication over another,” he says.
Choosing Disease Activity Measures
Rheumatoid Arthritis Disease Activity Measures: American College of Rheumatology Recommendations for Use in Clinical Practice highlights six disease-activity measures that are feasible to perform in a clinical setting; give a real-time score rather than a relative change measure; have defined ranges for low, moderate, and high disease activity; and include remission criteria.5 This document “acknowledges that you should measure disease activity in a formal fashion rather than as a gestalt,” Dr. Kazi says.