ACR CONVERGENCE 2020—More than 1 million individuals in the U.S. alone have rheumatoid arthritis (RA), making management of this condition a primary concern for rheumatologists.1 With this in mind, the ACR has drafted a new guideline for the management of RA.
During ACR Convergence 2020, Jeffrey Sparks, MD, MSc, assistant professor of medicine at Brigham and Women’s Hospital, Boston, moderated a series of presentations and a panel discussion with members of the committee that created the ACR’s new draft guideline on the pharmacologic management of RA. In these presentations, the methodology for creating the recommendations in the guideline was explained, the draft recommendations were presented, and several patient scenarios demonstrated how to apply the recommendations in clinical practice.
Liana Fraenkel, MD, MPH, adjunct professor at Yale School of Medicine, New Haven, Conn., and a rheumatologist at Berkshire Medical Center, Pittsfield, Mass., discussed the pharmacologic treatment recommendations for RA.
DMARD naive: For patients who are naive to disease-modifying anti-rheumatic drugs (DMARDs) and have moderate to high disease activity, methotrexate is strongly recommended over hydroxychloroquine, sulfasalazine, biologic DMARD and targeted synthetic DMARD monotherapy. Methotrexate is also conditionally recommended over leflunomide.
On the other hand, for a patient who is DMARD naive and has low disease activity, hydroxychloroquine is conditionally recommended over other conventional synthetic DMARDs; sulfasalazine is conditionally recommended over methotrexate; and methotrexate is conditionally recommended over leflunomide.
Maxed out on methotrexate: For patients who have not reached the target for disease control on maximally tolerated doses of methotrexate, the guidelines conditionally recommend adding a biologic DMARD or targeted synthetic DMARD instead of adding hydroxychloroquine and sulfasalazine (i.e., triple therapy).
This recommendation warranted further explanation from Joan Bathon, MD, director of the Division of Rheumatology at New York-Presbyterian Hospital/Columbia University Medical Center and professor of medicine at Columbia University College of Physicians and Surgeons, New York. She noted that although studies have shown the non-inferiority of triple therapy compared with a tumor necrosis factor inhibitor (TNFi) with methotrexate, the faster onset of action with biologic DMARDs and targeted synthetic DMARDs was particularly valued by the patient panel involved in the development of these guidelines.2 It’s likely that adherence to a treatment plan of methotrexate plus a biologic DMARD or targeted synthetic DMARD may be higher than that of triple therapy.
Lungs, Heart & More
The new draft guideline addresses several special patient populations and situations.