A systematic review of guidelines for managing rheumatoid arthritis

Abstract

BackgroundWe systematically reviewed current guidelines for managing rheumatoid arthritis (RA) to evaluate their range and nature, assess variations in their recommendations and highlight divergence in their perspectives.MethodsWe searched Medline and Embase databases using the terms ‘clinical practice guidelines’ and ‘rheumatoid arthritis’ from January 2000 to January 2017 together with publications of national and international bodies. We included guidelines providing recommendations on general RA management spanning a range of treatments and published in English. We undertook narrative assessments due to the heterogeneity of the guidelines.ResultsWe identified 529 articles; 22 met our inclusion criteria. They were primarily developed by rheumatologists with variable involvement of patient and other experts. Three dealt with early RA, one established RA and 18 all patients. Most guidelines recommend regular assessments based on the Outcome Measures in Rheumatology core dataset; 18 recommended the disease activity score for 28 joints. Twenty recommended targeting remission; 16 suggested low disease activity as alternative. All guidelines recommend treating active RA; 13 made recommendations for moderate disease. The 21 guidelines considering early RA all recommended starting disease modifying drugs (DMARDs) as soon as possible; methotrexate was recommended for most patients. Nineteen recommended combination DMARDs when patients failed to respond fully to monotherapy and biologics were not necessarily indicated. Twenty made recommendations about biologics invariably suggesting their use after failing conventional DMARDs, particularly methotrexate. Most did not make specific recommendations about using one class of biologics preferentially. Eight recommended tapering biologics when patients achieved sustained good responses.ConclusionsFive general principles transcend most guidelines: DMARDs should be started as soon as possible after the diagnosis; methotrexate is the best initial treatment; disease activity should be regularly monitored; give biologics to patients with persistently active disease who have already received methotrexate; remission or low disease activity are the preferred treatment target.

Reconsidering the Role of Melatonin in Rheumatoid Arthritis

“…Proinflammatory cytokines that mediate the progression of RA disease include tumor necrosis factor alpha (TNF-α), interleukin 1 beta (IL-1β), and IL-6. Current international guidelines for patients with early RA recommend starting disease-modifying antirheumatic drugs (DMARDs) as soon as possible, with methotrexate being the preferred choice [2]. Methotrexate is usually supplemented with short-term, low-dose oral or intra-articular glucocorticoids (GCs) for fast relief of pain and swelling and for arresting the inflammatory process.…”

“…Methotrexate is usually supplemented with short-term, low-dose oral or intra-articular glucocorticoids (GCs) for fast relief of pain and swelling and for arresting the inflammatory process. GCs must be carefully managed to prevent their inappropriate use and tapered as soon as possible to avoid long-term adverse effects [2]. The highly efficacious biologic DMARDs targeting the proinflammatory cytokines and Janus kinase inhibitors are intended for patients with persistently active 2 of 10 disease after initial methotrexate failure and, in some cases, another conventional DMARD [2].…”

“…GCs must be carefully managed to prevent their inappropriate use and tapered as soon as possible to avoid long-term adverse effects [2]. The highly efficacious biologic DMARDs targeting the proinflammatory cytokines and Janus kinase inhibitors are intended for patients with persistently active 2 of 10 disease after initial methotrexate failure and, in some cases, another conventional DMARD [2]. However, although these novel medications help to control RA disease activity, they are not universally effective in all RA patients [3,4] and many will lose therapeutic responsiveness after a period of time [5].…”

Methotrexate and Oral Antirheumatic Drugs

“…Subsequently, other agents that could target interleukin-6 (IL-6) and a fusion protein of cytotoxic T-lymphocyte associated antigen 4 (CTLA-4) and Fc portion of immunoglobulin G were also approved as therapies for RA. Furthermore, low molecular weight compound inhibitors against janus kinase (JAK) have also been approved 1) . These agents are highly effective in RA treatment and have made it possible to shift the goal of RA treatment to structural and functional remission instead of just clinical remission, as was the case before.…”

2019 update: EULAR RA management recommendations, efficacy and safety systematic literature reviews

“…RA management guidelines have been popular for the last two and a half decades and have recently undergone meta-analysis 2. EULAR committee defined in 2004 the standard operating procedures required to tackle such a task 3…”