New RA guideline emphasizes maximizing methotrexate and biologics, minimizing steroids

The American College of Rheumatology (ACR) will preview its 2020 Guideline for the Management of Rheumatoid Arthritis (RA) at ACR Convergence, the ACR's annual meeting. The comprehensive, clinical recommendations for pharmacologic treatment of RA includes important updates to the previous guideline released in 2015.

Rheumatoid arthritis (RA) is the most common type of chronic inflammatory arthritis. In RA, the immune system, the body's defense system against disease and injury, is not working properly. RA commonly causes pain and swelling in the wrist and small joints of the hand and feet but can affect almost all joints. Treatments for RA can stop joint pain and swelling and may also prevent joint damage. Early treatment will give patients with RA better long-term results.

While these recommendations focus solely on drug treatments for RA, future ACR guidelines will include non-drug therapies and vaccines. The new guideline was developed by a broad range of stakeholders in RA treatment, including rheumatologists, methodologists, and patients living with the disease.

"Patients with RA were involved at every step of the process and these recommendations truly reflect their perspectives. By including their personal experiences with different therapies, including their effectiveness, ease of use and side effects, the recommendations reflect the ACR's goal of shared decision making between the rheumatologist and patient," says Principal Investigator Liana Fraenkel, MD, MPH, professor adjunct in the Division of Rheumatology, Allergy and Immunology at Yale University School of Medicine. Fraenkel will discuss the recommendations at a press conference on Monday, Nov. 9 at 8:30 a.m. (ET).

Recommendations emphasize:

• Starting patients on methotrexate and continuing with the treatment instead of rapidly switching to another disease-modifying anti-rheumatic drug (DMARD). "We offer rheumatologists guidance on the nuances of how to really maximize the use of methotrexate in these patients," says Dr. Fraenkel.

New recommendations include:

• Minimizing the use of glucocorticoids, or steroids, to treat RA inflammation, due to the serious side effects associated with these drugs. "This conditional recommendation was based on the significant side effects of steroids."
• A change from past recommendations to escalate to triple therapy before starting a biologic. "Now, we recommend that rheumatologists add a biologic or a targeted synthetic DMARD instead of switching patients to triple therapy."
• New, specific recommendations on drug tapering and treatment of patient populations not covered in previous guidelines, including those with subcutaneous nodules, pulmonary disease, non-alcoholic fatty liver disease, persistent hypogammaglobulinemia and non-tuberculous mycobacterial lung disease. Because patients with RA may develop complications affecting their livers, eyes, lungs and just about every organ system, physicians from other specialties were invited to review clinical questions and provide input to the voting panel.

RA is a complex disease that may affect patients in different ways, so rheumatologists often need to individualize management approaches and decision making. Also, new pharmacologic agents are being approved for RA at a rapid pace, expanding the treatment options for this disease.

"Despite the many treatment recommendations included in this guideline, there are a number of remaining questions to address in more frequent, future updates. This guideline is a living document. As more therapies for RA emerge, we will modify what we recommend now," she says.

Recommendations were developed by panelists using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology to assess available evidence from current scientific literature.

The manuscript, containing the full list of recommendations and supporting evidence, is currently under review and is anticipated to be simultaneously published in Arthritis Care & Research and Arthritis & Rheumatology by fall 2020, pending completion of peer review.