Although lauding the recommendations for nicely condensing the past seven years of advances, Dr. Deodhar suggests that using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology without modifications (that were used in the current recommendations) may make future recommendations more relevant to clinical practice.
When using the GRADE methodology, investigators first look at questions of interest to clinical outcomes to generate the types of studies to include in the systematic review of the literature. These are called PICO (population, information, comparator and outcome) questions. Such an approach focuses first on the important clinical questions of interest to rheumatologists, and, therefore, the recommendations are tailored toward specific clinical situations.
“My suggestion is that next time [the recommendations are updated], the investigators start with the PICO questions and address what the important clinical questions are for rheumatologists,” he says. “Then, base the recommendations on that.”
Although the current recommendations did use the GRADE methodology, it used a modified form in which the investigators began with overarching questions on what data were available on the treatment of the various domains of PsA, followed by a literature search to find data on the efficacy and safety of these data. According to Dr. Kavanaugh, although the GRADE methodology is quite useful for very limited questions that fit either/or treatment decisions, it is less helpful with heterogeneous diseases, such as PsA, that have multiple potential therapies,because such a methodology would generate myriad questions that would be too numerous to tackle.
Live Document
Another update to the current recommendations may not be too far off. Both Drs. Kavanaugh and Deodhar emphasize that the rapid evolution of changes in the understanding and treatment of PsA mandates the need to update these recommendations continuously.
“In such a rapidly changing field, it is good to be on the lookout for new recommendations, because even though the current recommendations are brand new, there is already new information on the short horizon that will be useful,” says Dr. Kavanaugh.
Calling the recommendations a live document, Dr. Deodhar says he hopes the recommendations will be updated on an ongoing basis to meet the rapid pace of drug discovery and new questions that arise for the clinician on how to implement these drugs.
One pressing issue already, he says, is the need to provide clinicians with guidance on how to use the recently approved first biosimilar to treat PsA.
Dr. Kavanaugh acknowledges the need for continual updating to meet the ongoing challenge presented by the rapid pace of change. “The challenge is that there are newer therapies and treatment strategies that are being tested in ongoing studies, and there is a lag time between when the results are presented at an international meeting and when they are published,” he says. He says part of the challenge is to adhere to producing evidence-based guidelines while not spending too much time and effort on a document that will be outdated soon after it is published.
