- The use of DMARDs, biologics, tofacitinib and glucocorticoids in patients with early RA (less than six months) and established RA (six months or more),
- Recommendations on using a treat-to-target approach, tapering and discontinuing medications;
- The use of biologics and DMARDs in high-risk RA patients with comorbidities (i.e., hepatitis, congestive heart failure, malignancy and serious infections);
- The use of vaccines in patients starting/receiving DMARDs or biologics;
- Screening for tuberculosis in patients starting/receiving biologics or tofacitinib; and
- Laboratory monitoring for traditional DMARDs.
“The guideline includes recommendations designed to serve as a guide for patients and physicians to discuss evidence-based treatment options and collectively determine the best course of action for their care,” explained Jasvinder Singh, MD, MPH, a rheumatologist at the University of Alabama who served as principal investigator for the guideline project. “They address what we [the guideline development team] felt were the most common clinical scenarios physicians face when treating RA and helping patients manage the condition.”
Of the recommendations included, 23% are strong and 77% are conditional. A strong recommendation means the panel was confident that the desirable effects of following the recommendation outweighed the undesirable effects (or vice versa), so the course of action would apply to most patients, and only a small proportion would not want to follow the recommendation. A conditional recommendation means the desirable effects of following the recommendation probably outweigh the undesirable effects, so the course of action would apply to the majority of patients, but some may not want to follow the recommendation. Because of this, conditional recommendations are preference-sensitive and always warrant a shared decision-making approach between clinicians and patients.
Singh notes there a few differences between the development of the 2015 guidelines and previous ACR RA guidelines.
“The new guideline was developed using the GRADE methodology [Grading of Recommendations Assessment, Development and Evaluation], because it provides an internationally accepted systematic approach to guideline development. Important features of the GRADE method include the very clear specification of patient groups, interventions, competing treatment alternatives and outcomes; grading the quality of the evidence used; and basing recommendation strength on evidence quality, balance of benefits and harms, patient preference of treatment options, as well as clinical experience and expertise.”