ACR CONVERGENCE 2020—More than 1 million individuals in the U.S. alone have rheumatoid arthritis (RA), making management of this condition a primary concern for rheumatologists.1 With this in mind, the ACR has drafted a new guideline for the management of RA.
Dr. Sparks
During ACR Convergence 2020, Jeffrey Sparks, MD, MSc, assistant professor of medicine at Brigham and Women’s Hospital, Boston, moderated a series of presentations and a panel discussion with members of the committee that created the ACR’s new draft guideline on the pharmacologic management of RA. In these presentations, the methodology for creating the recommendations in the guideline was explained, the draft recommendations were presented, and several patient scenarios demonstrated how to apply the recommendations in clinical practice.
Dr. Fraenkel
Treatment Recommendations
Liana Fraenkel, MD, MPH, adjunct professor at Yale School of Medicine, New Haven, Conn., and a rheumatologist at Berkshire Medical Center, Pittsfield, Mass., discussed the pharmacologic treatment recommendations for RA.
DMARD naive: For patients who are naive to disease-modifying anti-rheumatic drugs (DMARDs) and have moderate to high disease activity, methotrexate is strongly recommended over hydroxychloroquine, sulfasalazine, biologic DMARD and targeted synthetic DMARD monotherapy. Methotrexate is also conditionally recommended over leflunomide.
On the other hand, for a patient who is DMARD naive and has low disease activity, hydroxychloroquine is conditionally recommended over other conventional synthetic DMARDs; sulfasalazine is conditionally recommended over methotrexate; and methotrexate is conditionally recommended over leflunomide.
Maxed out on methotrexate: For patients who have not reached the target for disease control on maximally tolerated doses of methotrexate, the guidelines conditionally recommend adding a biologic DMARD or targeted synthetic DMARD instead of adding hydroxychloroquine and sulfasalazine (i.e., triple therapy).
This recommendation warranted further explanation from Joan Bathon, MD, director of the Division of Rheumatology at New York-Presbyterian Hospital/Columbia University Medical Center and professor of medicine at Columbia University College of Physicians and Surgeons, New York. She noted that although studies have shown the non-inferiority of triple therapy compared with a tumor necrosis factor inhibitor (TNFi) with methotrexate, the faster onset of action with biologic DMARDs and targeted synthetic DMARDs was particularly valued by the patient panel involved in the development of these guidelines.2 It’s likely that adherence to a treatment plan of methotrexate plus a biologic DMARD or targeted synthetic DMARD may be higher than that of triple therapy.
Lungs, Heart & More
The new draft guideline addresses several special patient populations and situations.
Rheumatoid nodules: For patients with subcutaneous rheumatoid nodules and moderate to high disease activity, methotrexate is conditionally recommended over alternative conventional synthetic DMARDs. For patients with progressive nodules who are already on methotrexate, switching to a non-methotrexate DMARD is conditionally recommended over the continuation of methotrexate.
Lung disease: Often, the subject of pulmonary disease and RA treatment arises in clinical practice, and it is addressed in the guideline. For patients with incidental, mild, stable airway or parenchymal lung disease with moderate to high RA disease activity, methotrexate is conditionally recommended over other DMARDs. While pre-existing lung disease is a risk factor for methotrexate-related pneumonitis, the overall risk of worsening lung disease attributable to methotrexate is uncertain. The recommendation was made in favor of methotrexate because of its important role as an anchor treatment in RA and the lack of alternatives with similar efficacy and/or superior long-term safety profiles.
Heart failure: In patients with heart failure who meet criteria for New York Heart Classification III or IV (i.e., class III: marked limitation of physical activity; less than ordinary physical activity leads to symptoms; and class IV: unable to carry on any physical activity without discomfort; symptoms of congestive heart failure present at rest) and have an inadequate response to conventional synthetic DMARDs, non-TNFi biologic therapy or targeted synthetic DMARD treatment is conditionally recommended over TNFi.
Liver disease: For patients with a history of hepatitis B, prophylactic antiviral therapy is strongly recommended in patients positive for hepatitis B core antibodies or who are starting rituximab treatment, even if they test negative for hepatitis B surface antigens. Prophylactic antiviral therapy is also strongly recommended for patients positive for hepatitis B surface antigens who are starting any biologic or targeted synthetic DMARD. Frequent monitoring is conditionally recommended for patients who are positive for hepatitis B core antibodies and negative for hepatitis B surface antigens if they are starting a non-rituximab, biologic DMARD or targeted synthetic DMARD treatment.
Methotrexate is also conditionally recommended over other DMARDs in patients with nonalcoholic fatty liver disease who are DMARD naive and have moderate to high disease activity, normal liver enzymes and function tests, and no advanced fibrosis.
Glucocorticoids: During the panel discussion, it was also noted that for patients who are DMARD naive and have moderate to high disease activity, DMARDs without short-term glucocorticoid use (i.e., less than three months) are conditionally recommended over DMARDs with short-term glucocorticoid use.
The speakers described how this recommendation is meant to encourage rheumatologists to limit the use of steroids as much as possible given the potential harms associated with this medication class. The members of the guideline committee noted that glucocorticoid use is appropriate to help patients with acutely active RA. However, minimizing steroid use to periods when such treatment is absolutely needed is the ideal path for rheumatologists to follow.
Tapering Recommendations
As part of the panel discussion, the subject of tapering medications arose, and the speakers provided helpful insight into the topic. Often when patients feel better with regard to their RA symptoms, they ask their rheumatologist if and when they can taper their medications to avoid potential side effects, save time and money with respect to treatment, and achieve other potential benefits.
For this draft guideline, a discussion of tapering was recommended only if a patient has achieved target disease control for at least six months. At that point, it would be reasonable for the rheumatologist to discuss tapering medications with the patient, while including a full and informed discourse about the potential for flares. Back-up plans for situations in which disease activity increases should also be addressed.
Dr. England
Implications
Finally, Bryant England, MD, PhD, assistant professor of internal medicine in the Division of Rheumatology, University of Nebraska Medical Center, Omaha, noted the committee has provided a roadmap for how the field of rheumatology can and should seek to answer the pressing research questions of our era.
By specifically working on the most clinically challenging and relevant issues, researchers can provide the data that will allow recommendations in future guideline documents to be made with strong evidentiary support. This approach will, in turn, help clinicians, who will be able to refer to robust data and recommendations to support what they do in clinical practice.
Jason Liebowitz, MD, completed his fellowship in rheumatology at Johns Hopkins University, Baltimore, where he also earned his medical degree. He is currently in practice with Skylands Medical Group, N.J.
References
- Hunter TM, Boytsov NN, Zhang X, et al. Prevalence of rheumatoid arthritis in the United States adult population in healthcare claims databases, 2004–2014. Rheumatol Int. 2017 Sep;37(9):1551–1557.
- O’Dell JR, Mikuls TR, Taylor TH, et al. Therapies for active rheumatoid arthritis after methotrexate failure. N Engl J Med. 2013 Jul 25;369(4):307–318.
