Rheumatoid arthritis is the most common autoimmune inflammatory arthritis in adults. RA has a significant negative impact on the ability to perform daily activities, including work and household tasks, and health-related quality of life, and it increases mortality.
Major changes in the new guidelines are recommendations on the use of a new therapeutic agent, tofacitinib, and information on tapering and discontinuing medications for patients who have gone into remission and exhibit no symptoms.
The guidelines address six major topics:
- Use of traditional disease-modifying antirheumatic drugs — called DMARDs — along with biologics and tofacitinib
- Use of glucocorticoids
- Use of biologics and DMARDs in high-risk populations
- Use of vaccines in patients starting/receiving DMARDs or biologics
- Screening for tuberculosis in the context of biologics or tofacitinib
- Laboratory monitoring for traditional DMARDs
The principal investigator on the current guideline, Jasvinder Singh, M.D., in the Department of Medicine, UAB School of Medicine, was also the principal investigator and lead author of the 2012 guidelines. The previous RA guideline in 2008 was led by UAB’s Kenneth Saag, M.D.
The overall effort involved investigators from 18 U.S. and international institutions divided into a core leadership team, a voting panel, a literature review team and a content panel.
“These guidelines should serve as a tool for clinicians and patients for pharmacological treatment decisions in commonly encountered clinical situations,” said Singh, a professor in the UAB Division of Clinical Immunology and Rheumatology. “These recommendations are not prescriptive, and the treatment decisions should be made by physicians and patients through a shared decision-making process taking into account patients’ values, preferences and comorbidities. These recommendations should not be used to limit or deny access to therapies.”
The investigators used the Grading of Recommendations Assessment, Development and Evaluation — or GRADE — methodology to rate the quality of evidence. The GRADE process employs a group consensus to grade the strength of recommendations, either strong or conditional. A strong recommendation indicates that clinicians are certain that the benefits of an intervention far outweigh the harms or vice versa. A conditional recommendation denotes uncertainty over the balance of benefits and harms and/or more significant variability in patient values and preferences.
Singh says that rapid advances in therapies for RA, coupled with new knowledge of the mechanism of the disease, means these guidelines may have to be revised sooner than the usual three- to four-year time frame.
“Two decades ago, our treatment aim was to help patients regain some level of function, whatever that might be,” Singh said. “Now, with advances in knowledge and medications, we are working to return people to pre-disease status, to normal function.”
The full report on the guidelines is available here.
The core leadership team consisted of Singh, Saag and S. Louis Bridges, M.D., Ph.D., of UAB; Elie A. Akl, M.D., Ph.D., American University of Beirut, Beirut, Lebanon, and McMaster University, Hamilton, Ontario, Canada; and Timothy McAlindon, M.D., Tufts Medical Center, Boston, Massachusetts.
Other institutions represented in the effort were Beth Israel Deaconess Medical Center, Boston; University of California, Los Angeles; Washington University School of Medicine, St. Louis; University of California, San Diego; University of Nebraska Medical Center, Omaha; North Mississippi Medical Center, Tupelo; Healthy Motivation, Santa Barbara, California; Mayo Clinic, Rochester; University of Minnesota and Park Nicollet Clinic, St. Louis Park; NorthShore University Health System, Evanston, Illinois; Global Healthy Living Foundation, Inc., New York; Duke University Medical Center, Durham, North Carolina; Rheumatology Consultants of Oregon, LLC, West Linn, Oregon; and the American College of Rheumatology, Atlanta.