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

"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."

2015 American College of Rheumatology guideline for the treatment of rheumatoid arthritis

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.

Therapy of rheumatoid arthritis: new developments and trends.

The medical therapy of rheumatoid arthritis (RA) has been influenced strongly during the past decade by the recognition that many patients develop joint damage within the first year of disease. This observation has motivated rheumatologists to initiate disease-modifying antirheumatic drugs (DMARDs) early in the disease course. This trend has been matched by the increased use of combination DMARD therapy, with the aim to maximize control of the signs and symptoms of RA and limit the development of joint damage. The results from controlled clinical trials generally have supported the concept that early, aggressive treatment with DMARDs is superior to less intensive strategies. In addition, certain DMARD combinations are more effective than the individual components of these regimens, but the evidence is strong for only a few DMARD combinations such as methotrexate and cyclosporine A. Three new drugs have been recently approved for the treatment of RA. Celecoxib, a selective cyclooxygenase-2 inhibitor, has similar clinical efficacy as conventional nonsteroidal anti-inflammatory drugs, and in short-term studies causes no more gastric and duodenal ulcers and erosions than patients treated with placebo. Treatment with leflunomide, an inhibitor of pyrimidine synthesis, has been shown in controlled clinical trials to produce significant clinical improvement in 50% to 60% of patients with RA and delay radiologic progression of disease. The era of biologic therapy has dawned with the apparent success of tumor necrosis factor (TNF)-alpha blockade using etanercept, a recombinant TNF receptor:Fc fusion protein, and infliximab, a chimeric anti-TNF monoclonal antibody. These new agents expand our treatment options in RA and should lead to innovative and more effective treatment approaches.