Sessions on rheumatoid arthritis are guaranteed crowd-drawers in any rheumatology conference. Speakers discussing guidelines draw attention because it is a challenge keeping up with the evidence and guidelines, hopefully, put things in perspective. You can just imagine how exciting a session on RA guidelines would be. I remember attending several where the ACR 2015 guidelines (get them here) were featured even before it could see print. Overviews of the algorithms made everyone excited.
But after finally going through the final print, i can say that I’m divided on what to feel. Some items affirmed what we have been doing all along. But many parts were confusing and, at times, seem to go against reason.
But before going into that, let’s go over the reinforcements made by the paper.
Rheumatoid arthritis needs to be treated early. We can see a change in definitions that reflect this. Whereas the 2008 ACR Guide defined early RA as the period within 12 months (and very early RA as 3 months from), the current guidelines shifts the time frame to 6 months after symptoms start. After this, the patient is said to have established RA. I recall there being another class – long standing RA – but I guess it was removed since it had no practical application in the decision to treat and since this was a subset rarely (or never?) touched in intervention trials.
When starting treatment, regardless of disease activity AND duration of symptoms, start with DMARD monotherapy preferably methotrexate. After going through several discussions on whether to use step up (start with a single DMARD then add more agents if activity remains high) or step down (start with combination treatment then reduce meds if activity remains low), the final verdict goes to the former. Aside from costs, MTX monotherapy offers a balance between efficacy, safety, tolerability and acceptance by patients. However, as recognized by the paper, we should keep in mind that some patients may be willing to try the step down approach to achieve remission and relief at a much earlier time. And with this, we should recognize patient preference as a major factor in choosing therapy.
For all patients with RA, a treat to target approach should always be employed. Gone are the days when gestalt was the main basis for adjusting treatment. More objective means of assessing disease activity are available. In fact, ACR recognizes 6 of them (can you name them all?). But surprisingly, the authors made special mention of two – the ACR/ EULAR Boolean Definition of Remission and the Simplified Disease Activity Index. I guess people have come around to realizing that (1) complicated disease activity measures are best used in research but are less practical in the clinics (Admittedly, I still use this on my patients); and, (2) DAMs based solely on patient reported outcomes do not paint a complete picture. I recall the recent letter to the editor by Booers (Ann Rheum Dis 2016; 0:1. doi:10.1136/annrheumdis-2016-210063) asking groups to just focus on the two DAMs mentioned above as others didn’t perform as well in defining remission.
When patients have moderate to high disease activity, do something, anything – don’t just maintain them on the same regimen. Corollary to the treat to target approach, the goal should be remission. If this is not possible then aim for low disease activity. Don’t allow patients to be in moderate to high activity as this correlates with the level of inflammation – which leads to joint damage. This in turn will eventually correlate with the quality of life and level of disability. Variations may occur as to which drugs (or combinations) will be used by a physician. This is acceptable as long as the goal in mind is disease remission.
Once remission is achieved, don’t stop all RA medications at the same time. Authors advise us to taper the medications one by one. As to how this is done, there are no formal documents to instruct us on this. A recent concept that I’ve come across (in another journal) is “Taper To Target” – simply put, it just means that as we wean the patient off RA therapies, we have to continue monitoring disease activity and ensure patients stay in remission. If using IV therapies, a 25% reduction in the dose every 3-6 months can be done provided the patient remains in remission. If the patient is on SC therapies, interval between shots can be increased by 50% every 3-6 months if remission is also maintained. Should a flare occur during the process, a short course of steroids and/or titrating up DMARDs may be used.
These are the affirmations I had after reading the document. On the next part, I’ll discuss some opportunities I felt were missed by the 2015 guidelines.