In 2008, the American College of Rheumatology (ACR) issued guidelines for the use of non-biologic and biologic treatments in rheumatoid arthritis (RA). Much has changed in the years since the last recommendations, with the availability of new drugs and increased experience with the older agents. The ACR guideline update, which was published in the May 2012 issue of Arthritis Care & Research, focuses on early treatment, special considerations for high-risk patients, and screening for tuberculosis.
“The 2012 update re-emphasizes the importance of more aggressive treatment in early RA.”
The ACR update re-emphasizes the importance of aggressive treatment in early RA. In addition to better outcomes, early intensive treatment can help patients maintain physical function and quality of life. Prevention is critical because joint damage resulting from RA is permanent once it occurs. It should be noted that the updated recommendations focus on common clinical scenarios. They should be used as a guide for clinicians with the clear understanding that the best treatment decisions can only be made by having collaborative dialogue with patients. For each patient, physicians must consider:
The risks and benefits of treatment.
Comorbidities and concomitant medications.
Practical economic considerations.
Rheumatoid Arthritis Treatment Recommendations
The goal of early RA treatment is for remission or at least low disease activity. For patients who have been symptomatic for 6 months or less, the usual approach should be disease-modifying antirheumatic drug (DMARD) monotherapy. If disease activity is moderate or high and patients have poor prognosis, combination DMARD therapy can be tried. If disease activity is high in early RA and the prognosis is poor, an anti-tumor necrosis factor (TNF) biologic agent can be used in combination with methotrexate or alone.
Patients who show no response after 3 months on anti-TNF agents can be switched to another anti- TNF drug or to a non-TNF biologic therapy. Those who have taken a non-TNF biologic for 6 months but have had an inadequate response can be switched to a TNF or non-TNF biologic. Patients with high disease activity who have failed TNF treatment because of serious adverse events should be switched to a non-TNF biologic. However, another anti-TNF agent or a non-TNF biologic can be used if the adverse event was not considered serious.
Importantly, the guideline update has revised treatment recommendations on the use of biologics for patients with RA at higher risk because of comorbid conditions, most notably hepatitis C, solid tumors or non-melanoma skin cancers, and congestive heart failure. It also revised recommendations on screening for latent tuberculosis infection, which should be done for all patients before starting biologic therapy. More detailed recommendations on these aspects of the guidelines—as well as recommendations for early RA treatment—can be found here.
Singh JA, Furst DE, Bharat A, et al. 2012 update of the 2008 American College of Rheumatology recommendations for the use of disease-modifying antirheumatic drugs and biologic agents in the treatment of rheumatoid arthritis. Arthritis Care Res. 2012;64:625-639. Available at: http://www.rheumatology.org/practice/clinical/guidelines/Singh%20et%20al-ACR%20RA%20GL-May%202012%20AC&R.PDF.
Anderson J, Caplan L, Yazdany J, et al. Rheumatoid arthritis disease activity measures: American College of Rheumatology recommendations for use in clinical practice. Arthritis Care Res. 2012;64:640-647. Available at: http://www.rheumatology.org/practice/clinical/forms/RADAM-May%202012-AC&R.pdf.
Daikh D, St. Clair E. Updated recommendations for the treatment of rheumatoid arthritis: another step on a long road. Arthritis Care Res. 2012;64:648-651.
Saag KG, Teng GG, Patkar NM, et al. American College of Rheumatology 2008 recommendations for the use of nonbiologic and biologic disease-modifying antirheumatic drugs in rheumatoid arthritis. Arthritis Rheum. 2008;59:762-784.