Canadian Rheumatology Association Living Guidelines for the Pharmacological Management of Rheumatoid Arthritis With Disease-Modifying Antirheumatic Drugs

Abstract

Objective To provide the initial installment of a living guideline that will provide up-to-date guidance on the pharmacological management of patients with rheumatoid arthritis (RA) in Canada. Methods The Canadian Rheumatology Association (CRA) formed a multidisciplinary panel composed of rheumatologists, researchers, methodologists, and patients. In this first installment of our living guideline, the panel developed a recommendation for tapering of biologic and targeted synthetic (b/ts) DMARD therapy in patients in sustained remission using the GRADE approach, including a health equity framework developed for the Canadian RA population. The recommendation was adapted from a living guideline of the Australia & New Zealand Musculoskeletal Clinical Trials Network. Results In people with RA who are in sustained low disease activity or remission for at least 6 months, we suggest offering stepwise reduction in the dose of b/tsDMARD without discontinuation, in the context of a shared decision, provided patients are able to rapidly access rheumatology care and re-establish their medications if needed. In patients where rapid access to care or re-establishing access to medications is challenging, we conditionally recommend against tapering. A patient decision aid was developed to complement the recommendation. Conclusion This living guideline will provide contemporary RA management recommendations for Canadian practice. New recommendations will be added over time and updated, with the latest recommendation, evidence summaries and evidence to decision summaries available through the CRA website (www.rheum.ca).

From Canadian Living Guidelines to Global Living Guidelines: A Post Pandemic Effort

“…5 What living guidelines? The evidence used by Hazlewood et al 1 was that of the Australian living guidelines and that data was contextualized to the Canadian Health System with emphasis on health equity. In this process, the recommendation implications for populations at risk for inequities (ie, rural and remote residents, Indigenous peoples, elderly persons with frailty, minority populations of first-generation immigrants and refugees, persons with low socioeconomic status or who are vulnerably housed, and sex and gender populations) were considered.…”

“…In this issue of The Journal of Rheumatology, Hazlewood et al provide living recommendations on the issue of biologic (b-) and targeting synthetic (ts-) disease-modifying antirheumatic drug (DMARD) de-escalation in adults with rheumatoid arthritis (RA). 1 The panel recommends that patients with RA in sustained remission or low disease activity for at least 6 months and ideally 12 months, upon glucocorticoid discontinuation, are offered a trial of stepwise tapering (ie, extension of interval between doses or dose reduction) but no discontinuation of bDMARD (ie, originator and biosimilars) and tsDMARD therapy. This is a conditional recommendation, meaning that "the majority of people with RA in this situation would want the suggested course of action, but many would not."…”

“…This is a conditional recommendation, meaning that "the majority of people with RA in this situation would want the suggested course of action, but many would not." 1 This recommendation is meant to be based on a shared decision including the discussion of a flare management plan and only in patients who have rapid access to rheumatology care in case of flare. If access to care is limited, the panel conditionally recommended against tapering.…”

Canadian Rheumatology Association Living Guidelines for Rheumatoid Arthritis: Update #1

“…These add to our prior recommendation for tapering of advanced therapy. 1 The full list of best practice statements and treatment recommendations is summarized (Table ). Readers should always consult the online version of the guideline, 2 which will always be the latest version with all recommendations, and include important contextual information for each recommendation, along with supporting evidence summaries.…”

“…When citing the guidelines, both the original journal publication and online version should be cited, as these describe the full methods of development. 1,2 Authors may choose to also cite other update articles.…”