ACR drafts inaugural guideline for integrated care for RA

A new guideline on rheumatoid arthritis (RA)—the first ACR guideline for integrated interventions for this disease—provides direction on treatment through a shared decision-making approach.

On Sunday, November 13, members of the project team presented the new recommendations in ACR Guideline for Physical, Psychosocial, Mind-body, and Nutritional Interventions for Rheumatoid Arthritis: An Integrative Approach to Treatment. The session is available for on-demand viewing for registered ACR Convergence participants through October 31, 2023, on the virtual meeting website.

A group of interdisciplinary experts contributed to the creation of the clinical framework for the guideline, including a core team of seven leaders, a literature review team, a voting panel, a patient panel, and ACR staff. The collaboration yielded 28 recommendations, including one strong recommendation and 27 conditional recommendations, to guide interprofessional teams providing patient-centered care.

“We established early on that the optimal treatment outcome for patients with RA, it’s not with one provider,” said Bryant England, MD, PhD, RhMSUS, Associate Professor of Medicine, University of Nebraska Medical Center. “It’s not one clinician who’s going to be able to answer all their questions. It really requires an interprofessional team to provide the best care for our patients.”

The singular strong recommendation in the guideline advises consistent engagement in exercise for patients with RA. Which type of exercise to engage in depends on the patient and their circumstances at any given time, but conditional recommendations were made for aerobic, aquatic, resistance, and mind-body activities. The team also established conditional recommendations related to patients’ diets, rehabilitation, and additional integrative interventions.

The panel demonstrated how to put the recommendations into practice through a case discussion following a patient, “Alex,” from early diagnosis through a decade of living with RA. The panel emphasized that every patient requires a personalized care plan based on that person’s condition, access to resources, and lifestyle.

“We could recommend a Mediterranean diet, if this is something that would fit in Alex’s life,” explained Jennifer Barton, MD, Rheumatology Section Chief at the VA Portland Health Care System and Associate Professor of Medicine at Oregon Health & Science University. “Again, this is really [about] understanding the context of Alex’s situation, access to food, how the food’s prepared, and Alex’s capacity to follow through on these things.”

The same philosophy applies to physical activity.

“We want to find the kind of exercise that is most comfortable, most tolerable, and most enjoyable for Alex to participate in,” said Carol Oatis, PhD, PT, Professor Emerita at Arcadia University. “That may require some guidance from a PT or an OT.”

As the disease progresses, patients with RA often require increasingly advanced, collaborative care interventions.

“This is a life-changing disease, and it’s chronic, and it doesn’t go away,” said Kaleb Michaud, PhD, Professor, University of Nebraska Medical Center. “Having these conversations earlier [rather] than later can make a huge difference.”

Providers must assess patient capacity and challenges to identify a path forward, preferably in conjunction with minimally disruptive medicine to minimize the patient’s burden.

“It’s almost like a puzzle,” said Nancy Baker, OT, MPH, ScD, Associate Professor and Chair of the Department of Occupational Therapy, Tufts University. “It’s working to identify what the problem is and then what is the best way to solve that problem. It’s going to be different for every person. The health professionals really are just providing knowledge so that the client can make the decision about what will work best for them.”

The comprehensive guideline summary can be found on the ACR website. The final guideline publication in Arthritis Care & Research and Arthritis & Rheumatology is anticipated in spring 2023.