The American College of Rheumatology recently issued new guidelines for rheumatologists to use in their patient treatment decisions about the use on non-biologic and biologic disease modifying anti-rheumatic drugs (DMARDs).  The recommendations and guidelines were published in the June issue of the journal, Arthritis Care & Research.

The guidelines are intended to provide guidance to physicians and are voluntary, but are not meant to dictate treatment for every patient, since needs and circumstances vary with each individual patient.

The recommendations take into account five key areas:

• indications for starting or resuming DMARD use
• contraindications for DMARD use
• monitoring for side effects
• assessing clinical response
• preventive immunizations and screening for tuberculosis.

For biologic DMARDs, they also considered cost and patient preferences in decision-making.

The guidelines include only a selection of drugs.

The non-biologics include:

• droxychloroquine
• leflunomide
• methotrexate
• minocycline
• sulfasalazine 

The biologics include:

• abatacept
• infliximab
• adalimumab
• etanercept
• rituxumab

The drugs included seem to be the most common or have more studies and literature available, don't have as high of an incidence of adverse events as drugs not included, or are not indicated for patients starting or resuming DMARD treatment. Also, since there are more than 170 possible dual and triple non-biologic DMARDs drug combinations to choose from, the ACR only included recommendations that were best supported by evidence or used the most commonly. 

How this affects me

In reading the guidelines, I noticed that my current drug regimen doesn't really match any of the guidelines.  But perhaps that's because most of these guidelines are written for people with relatively new disease, usually people who've had the disease for less than three months, less than six months, between 6 and 12 months and people who've had the disease just 6 months to two years. The goal, of course, would be to stop or slow the progression of the disease as soon as possible, considering joint deterioration and damage occur over time.  I imagine that it is much more difficult to write effective treatment guidelines for someone like me.  I was diagnosed with JRA in 1976 and have taken a multitude of different medications over the years.  My treatment now is more about maintenance than stopping disease progression.  It also includes more questions and answers with my doctor like, "Have you taken XYZ and if so, when?", "How did it work for you?  Did you have any reactions?", "Are you planning to get pregnant any time soon?", "Let's try ABC, what do you think?"

However, I have decided to post highlights of the guidelines because I think they can be a useful tool for patients to consider in making their own treatment decisions. If you have been recently diagnosed or feel like your current treatment regimen is not working optimally, perhaps these can spark the interest for further reading about different drugs on this site.  Or perhaps they can facilitate discussion or stimulate questions to ask your doctor.