‘The development process was transparent, & our goal was consensus. Transparency is the key for our guidelines.’
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Explore This IssueMarch 2015
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Advisory recommendations are not proscriptive, said Jasvinder Singh, MD, MPH, associate professor of medicine at the University of Alabama, Birmingham, and principal investigator for this ACR project. However, they may help improve patient care and should be evidence based, he said.
“The development process was transparent, and our goal was consensus. Transparency is the key for our guidelines,” said Dr. Singh. “In the end, this is really good for our patients because it gives them more options.”
Together, the guideline developers found common ground on key issues in RA treatment, Dr. Singh said. These included disease-modifying antirheumatic drugs (DMARDs) before switching to a new therapy in various scenarios. However, “Arbitrary switching of therapies should not be done if the patient is doing well,” he said.
The guideline developers reviewed the medical literature on several RA-related topics, he added. These include the role of biosimilars in RA therapy, use of biologic drugs and DMARDs during pregnancy and breastfeeding, treatment of RA with interstitial lung disease and biomarker testing.
In the end, a recommendation is considered strong if the benefit of a therapy in a particular scenario outweighs the risks, Dr. Singh said. The ideal target for all of the RA treatment recommendations was low disease activity scores or remission.
Recommendations from the draft guidelines, which remain under review, include:
- An optimal dose of DMARD monotherapy is recommended for the first three months of treatment for patients both with low DAS and moderate to high DAS. Methotrexate is the first-line therapy for most RA patients.
- After three months, if methotrexate or any other DMARD fails, rheumatologists may try dose escalation or switching therapies.
- Short-term glucocorticoids may be given to DMARD-naive RA patients with any disease-activity level who experience a flare.
- DMARD-naive patients with established RA and either low or moderate to high disease activity should also start with DMARD monotherapy. If this fails, rheumatologists should switch to a combination therapy of multiple DMARDs, a TNFα-inhibitor with or without methotrexate, a non-TNF biologic with or without methotrexate, or tofacitinib and methotrexate.
- RA patients, even those in remission, should not discontinue therapy.
Audience members questioned the panel about why tofacitinib was not recommended for early RA and the role of intra-articular glucocorticoids for flares instead of oral drugs.