A new ACR guideline on integrative interventions for rheumatoid arthritis (RA) emphasizes the importance of patient preferences and shared decision making.1 Clinicians can use the guideline to open important conversations with patients about complementary aspects of their care.
Assessing Integrative Choices
“We have many potential modalities we can utilize to help manage rheumatoid arthritis that aren’t medications,” says Bryant R. England, MD, PhD, associate professor, Division of Rheumatology, University of Nebraska Medical Center, Omaha, and lead author of the new guideline. “These don’t replace medications, but can be used alongside them. Previously, the data had not been put together in an evidence-based fashion to systematically recommend or use those potential integrative interventions.”
Many patients bring up questions related to integrative approaches, such as diet, exercise and supplements, in their initial discussions on disease management, shares Dr. England.
“I think we all carry our own personal preferences, our own biases,” notes Dr. England. “That’s why it’s so critical to [approach this guideline] following a standardized methodology, so we can evaluate the evidence critically.”
The guideline repeatedly emphasizes the importance of shared decision making in integrative approaches. This partly reflects the fact that due to the evidence base, all but one of the recommendations are conditional. “You have to spend the time talking with the patient and understanding their values and preferences because that is going to meaningfully influence your therapy decisions,” he says.
It’s also important to consider these recommendations in the context of the patient’s comorbidities, which may also influence integrative therapy choices. Dr. England stresses the importance of providing patients with an overview of all their treatment options, including integrative ones, while not pressuring them to pursue too many at once.
Dr. England has been bringing up the guideline with patients to begin conversations about the importance of exercise (see sidebar, below). “They may have thought their rheumatologist only cared about whether or not they’re taking their methotrexate,” he says.
The guideline provides a strong recommendation for consistent exercise due to clear evidence of its role in improving patients’ function and reducing their pain. Additionally, the guideline provides separate conditional recommendations for aerobic exercise, aquatic-based exercise, resistance exercise and mind body exercises such as yoga and tai chi, with no specific recommendations ranking one approach above the others.
“An old belief that sometimes still circulates around the medical community is that people with rheumatoid arthritis shouldn’t exercise because it would damage their joints. But that’s not the case. We’ve seen through this systematic appraisal of the evidence that exercise benefits [rheumatoid arthritis] management,” says Dr. England.