American College of Rheumatology (ACR) printed 2021 Guidelines for Rheumatoid Arthritis
Key Take-aways
Unsurprisingly, ACR had a heavy focus on drug interventions favoring methotrexate. I was happy to see consensus around avoiding glucocorticoids when possible. This a huge step given the distress this product has on our gut microbiome, addictive properties, and never mind increases in mortality rates. ACR also addressed a therapy taper approach for patients who have achieved remission or low disease activity - finally.
ACR noted key outcomes desired for RA patients. Again, drug and pharma heavy. Interestingly, remission is not noted. Why is that? Does research not support remission? If we don't start demanding remission, will therapies and solutions to consistently achieve remission ever arise?
For those who're interested, here a high-lights from the recommendations:
- Strong emphasis on use of methotrexate with oral administration preferred
- Recommendation to avoid glucocorticoids whenever possible
- Recommendations to lead with methotrexate and add a biologic DMARD or targeted synthetic DMARD for methotrexate non-responders
- General lack of therapy comparative effectiveness research in rheumatology, which is a callout for more research needed in this area
- Patients who are in low disease activity or remission for at least 6 months can attempt reducing dosage or extending the interval between doses
Deep Dive
American College of Rheumatology (ACR) is an independent, professional, medical and scientific society. Through out medicine, societies, such as ACR, exist to develop guidelines for treating various diseases, among other things. These guidelines should be supported by significant evidence. Physicians, such as Rheumatologists, then treat patients based on the societies' guidelines.
"The ACR updates its clinical practice guidelines every 5 years at minimum. The 2021 guidelines for RA include a total of 44 recommendations, including 7 strong and 37 conditional items." (Healio)
7 strong recommendations:
- Methotrexate should be used over hydroxychloroquine or sulfasalazine in patients with moderate to high disease activity who are DMARD-naïve;
- Methotrexate monotherapy should be used over biologic or targeted synthetic DMARDs among patients with moderate-to-high disease activity who are DMARD-naïve;
- Methotrexate monotherapy should be used over combination therapy with methotrexate plus a non-TNF-inhibitor biologic or targeted synthetic DMARD among patients with moderate-to-high disease activity who are DMARD-naïve;
- Clinicians should start a conventional synthetic DMARD without longer-term glucocorticoids, rather than initiating such DMARDs with longer-term glucocorticoids, for DMARD-naïve patients with moderate-to-high disease activity;
- Clinicals should use a treat-to-target rather than usual care for patients who have not been previously treated with biologic or targeted synthetic DMARDs;
- Prophylactic antiviral therapy should be used, over frequent monitoring of viral load and liver enzymes alone, among patients starting rituximab (Rituxan, Genentech) who are positive for hepatitis B core antibodies, regardless of hepatitis B surface antigen status; and
- Prophylactic antiviral therapy should also be used, rather than frequent monitoring alone, for patients starting any biologic or targeted synthetic DMARD who are positive for hepatitis B core antibodies and hepatitis B surface antigen.
In addition, RCA recommends Rheumatologists focus on the following outcomes in the patient (mind you, these are most likely tied to physician compensation and how much insurance is willing to reimburse):
- Disease activity
- Function or functional activity (i.e. employment)
- Preventing joint damage
- Serious adverse events (i.e. opportunistic infections such as TB)
- Reversible side effects that are not "serious" but impact quality of life or decision making
- Percent stopping medication because of side effects
- Drug survival
- Quality of life
