A new ACR guideline for the management of rheumatoid arthritis (RA) has been drafted and is expected to be approved later this year and published by early spring 2021. An ACR Convergence 2020 session featured members of the guideline core oversight and expert panel teams, who discussed some of the key updates and new recommendations.
Registered attendees have on-demand access to watch a replay of the session, New ACR Recommendations for the Management of Rheumatoid Arthritis, through Wednesday, March 11, 2021.
Bryant R. England, MD, PhD, assistant professor of medicine in the Division of Rheumatology & Immunology at the University of Nebraska Medical Center, began the session with an overview of the guideline development process and the rationale for topics covered.
“The American College of Rheumatology regularly produces RA treatment guidelines to facilitate high-quality clinical care and, as evidence continues to evolve in the management of rheumatoid arthritis, it means that these guidelines need to be continually updated,” Dr. England said. “The most recent update was in 2015, and since that time there has been new evidence that’s emerged, including the FDA approval of three new therapies for the treatment of rheumatoid arthritis. Thus, it became imperative that the ACR update these RA treatment guidelines.”
The new guideline includes 44 recommendations, of which 7 are “strong” recommendations and 37 are “conditional,” Dr. England said. The draft manuscript of the guideline is undergoing peer review, with final approval expected later this year.
Liana Fraenkel, MD, MPH, followed with a review of some of the key changes/updates in the new guideline, including a number of pharmacologic therapy recommendations. Dr. Fraenkel is director of Patient Centered Population Health Research at Berkshire Medical Center and adjunct professor of medicine at Yale University, and principal investigator of the guideline.
Regarding DMARD monotherapy for DMARD-naïve patients with moderate-high disease activity, Dr. Fraenkel said that methotrexate is strongly recommended over hydroxychloroquine or sulfasalazine. Additionally, methotrexate is conditionally recommended over leflunomide and is strongly recommended over biologic DMARD or targeted synthetic DMARD monotherapy.
“In terms of DMARD mono- versus combination-treatment, methotrexate monotherapy is strongly recommended over methotrexate in combination with hydroxychloroquine or sulfasalazine. It is conditionally recommended over a conventional synthetic DMARD dual or triple combination [therapy],” Dr. Fraenkel said. “It is conditionally recommended over methotrexate in combination with a TNF inhibitor, and it is strongly recommended over methotrexate in combination with a non-TNF inhibitor, biologic, or a targeted synthetic DMARD.”
For patients who are DMARD naïve with low disease activity, she said that hydroxychloroquine is conditionally recommended over other conventional synthetic DMARDs, sulfasalazine is conditionally recommended over methotrexate, and methotrexate is conditionally recommended over leflunomide.
Among the recommendations related to administration of methotrexate, Dr. Fraenkel said that, when starting methotrexate, oral administration is conditionally recommended over subcutaneous.
“For patients who are not tolerating oral methotrexate, split dose or subcutaneous or increasing folic acid is conditionally recommended over switching to a new DMARD,” she said. “For patients who are not at target on oral methotrexate, switching to subcutaneous methotrexate is conditionally recommended over adding or switching to a new DMARD.”
Recommendations for patients who are not at target include a strong recommendation for a treat-to-target approach over usual care if patients are biologic and targeted synthetic DMARD naïve.
“A treat-to-target approach is conditionally recommended over usual care for patients who’ve had an inadequate response to at least one biologic or targeted synthetic DMARD,” Dr. Fraenkel said. “And a minimal initial treatment goal of low disease activity is conditionally recommended over remission; however, one should note that this does not preclude changing the treatment goal over time.”
Regarding the use of glucocorticoids, for patients requiring glucocorticoids to remain at target, she said that adding or switching DMARDs is conditionally recommended over continuing glucocorticoids.
“For patients on DMARDs and who are not at target, adding or switching DMARDs with or without the use of intraarticular glucocorticoids is conditionally recommended over the use of intraarticular glucocorticoids alone,” Dr. Fraenkel said.
Among other key updates, Dr. Fraenkel also reviewed recommendations for tapering medication and recommendations for specific high-risk populations.
In the final presentations of the session, Joan Bathon, MD, professor of medicine and chief of the Division of Rheumatology at Columbia University College of Physicians and Surgeons, and Stanley B. Cohen, MD, clinical professor at UT Southwestern Medical Center and co-director of the Division of Rheumatology at Presbyterian Hospital, Dallas, provided case-based scenarios to illustrate application of the guideline in clinical practice.