The ACR has published three documents intended to provide clarity and consensus on management of osteoarthritis, classification criteria for Sjögren’s syndrome, and classification criteria for polymyalgia rheumatica. The documents, which represent the most current clinical evidence, research, and expert panel input and review, can help inform clinical practice and provide clearer target populations for future research.
Rheumatologists involved in the development of these documents say that updated consensus was needed on each of the conditions. The previous ACR recommendations for management of hip and knee osteoarthritis (OA) were issued in 2000, and recommendations from other international groups have followed.1 Since that time, research has yielded new information about the safety and tolerability of treatments for OA, new therapies have become available, and the methodology for development of clinical practice guidelines has improved. Because the 2012 OA recommendations use a case-based approach built on common clinical scenarios, practitioners should recognize the patterns that they see in practice, according to Marc C. Hochberg, MD, MPH, head of the division of rheumatology and clinical immunology at the University of Maryland School of Medicine in Baltimore, and an author of the recommendations.
New classification criteria for Sjögren’s syndrome (SS) were needed, given the increasing availability of biologic agents to be tested as part of clinical trials for management of the disease, and the comorbidities associated with their use, according to Lindsey A. Criswell, MD, MPH, DSc, chief of the division of rheumatology at the University of California, San Francisco, and co-leader with Caroline Shiboski, DDS, MPH, PhD, of the Sjögren’s International Collaborative Clinical Alliance (SICCA) registry that was used for development of the criteria. Although 11 classification criteria sets have been issued over the past several years by other organizations, the 2012 criteria are the first endorsed by the ACR. Most important for classification, the new criteria rely solely on objective tests rather than symptoms.
The way polymyalgia rheumatica (PMR) is diagnosed and how PMR is classified for clinical studies varies among practitioners because PMR’s symptoms can mimic other conditions, and it has no disease-specific inflammatory markers or biomarkers. The 2012 EULAR/ACR classification criteria for PMR help clarify the key features in a difficult-to-classify condition, says Eric L. Matteson, MD, chair of the division of rheumatology at the Mayo Clinic in Rochester, Minn., and an author of the criteria. The listed criteria are the features most characteristic of PMR that expert clinicians use to diagnose the disease, and they formed the basis for evaluation of the new disease classification criteria. Although these criteria can help clarify some diagnostic issues, they are primarily intended to aid development of therapeutic approaches and further research on the disease itself, Dr. Matteson says.
Management of Osteoarthritis
Unlike previous ACR recommendations for management of OA, the “ACR 2012 Recommendations for the Use of Nonpharmacologic and Pharmacologic Therapies in Osteoarthritis of the Hand, Hip, and Knee” were developed using the GRADE (Grades of Recommendation Assessment, Development and Evaluation) approach, a formal method for developing recommendations that is “more valid and internationally acceptable,” Dr. Hochberg says.2 “Rheumatologists should recognize that this was a very rigorous process and one that is evidence based.” GRADE is now the preferred process by many professional organizations, including the World Health Organization, the Cochrane Collaboration, and the Agency for Healthcare Research and Quality.