2015 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis

Abstract

Objective To develop a new evidence‐based, pharmacologic treatment guideline for rheumatoid arthritis (RA). Methods We conducted systematic reviews to synthesize the evidence for the benefits and harms of various treatment options. We used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology to rate the quality of evidence. We employed a group consensus process 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. Results The guideline covers the use of traditional disease‐modifying antirheumatic drugs (DMARDs), biologic agents, tofacitinib, and glucocorticoids in early (<6 months) and established (≥6 months) RA. In addition, it provides recommendations on using a treat‐to‐target approach, tapering and discontinuing medications, and the use of biologic agents and DMARDs in patients with hepatitis, congestive heart failure, malignancy, and serious infections. The guideline addresses the use of vaccines in patients starting/receiving DMARDs or biologic agents, screening for tuberculosis in patients starting/receiving biologic agents or tofacitinib, and laboratory monitoring for traditional DMARDs. The guideline includes 74 recommendations: 23% are strong and 77% are conditional. Conclusion This RA guideline should serve as a tool for clinicians and patients (our two target audiences) for pharmacologic treatment decisions in commonly encountered clinical situations. 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.

Baricitinib, Methotrexate, or Combination in Patients With Rheumatoid Arthritis and No or Limited Prior Disease‐Modifying Antirheumatic Drug Treatment

“…In accordance with the ACR guideline and EULAR recommendations for the treatment of RA 6, 20, treatment should be initiated with an MTX regimen. The effectiveness of MTX in controlling disease activity, improving patient function, and limiting radiographic progression in up to one‐third of patients with early RA when used as monotherapy 21, 22 underpins these recommendations.…”

“…Furthermore, although current guidelines recommend MTX as initial DMARD therapy for patients with RA, slow onset of benefit is recognized, and use of corticosteroids to bridge to treatment response is suggested as part of initial therapy 6, 7. Compared to csDMARDs with delayed onset of effect, novel therapies with rapid onset of benefit may obviate the need for bridging corticosteroid use of this kind, a potentially desirable advance in light of the recognized toxicities of corticosteroid therapy.…”

Comparison of biosimilar CT-P10 and innovator rituximab in patients with rheumatoid arthritis: a randomized controlled Phase 3 trial

“…19 Patient access to innovator biologics such as RTX can, however, be restricted by cost, particularly in lower income countries. 20 Biosimilars offer financial savings and reductions in time for development and manufacture because the companies developing them can rely on the research efforts implemented for the reference product without jeopardizing efficacy and safety.…”

Brief Report: Remission Rates With Tofacitinib Treatment in Rheumatoid Arthritis: A Comparison of Various Remission Criteria

“…If remission (the absence of disease activity) is unattainable, particularly in patients with longstanding RA, a state of low disease activity is targeted 1, 2.…”