New Rheumatoid Arthritis Treatment Guidelines

Christine Miller Health Guide
  • 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:

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    • 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. 


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    • Leflunomide or methotrexate monotherapy is recommended for patients with all disease durations and for all degrees of disease activity, regardless of poor prognostic features (such as active disease with high tender and swollen joint counts; radiographic erosions; elevated rheumatoid factor or anti-CCP antibodies, SED rate or levels of C-reactive protein; early disability; age; and female gender.)
    • Sulfasalazine monotherapy is recommended for all patients with all disease durations and degrees of disease activity, but without poor prognostic features.
    • Hydroxychloroquine and minocycline are recommended for patients without poor prognostic features, with low disease activity and disease duration <24 months. 
    • The dual combination of methotrexate plus hydroxychloroquine is recommended for patients with moderate to high disease activity regardless of disease duration or poor prognostic features.  It is also recommended for patients with long disease duration and low disease activity.
    • Methotrexate plus sulfasalazine is recommended for patients of all disease durations and high disease activity and poor prognostic features. 
    • The triple combination of methotrexate, hydroxychloroquine and sulfasalazine is recommended for patients with poor prognostic features and high disease activity, regardless of disease duration.
    • The ACR recommends anti-TNF agents in combination with methotrexate in early RA (<3 months) only for patients with high disease activity and who haven't taken DMARDs before. 
    • For patients with intermediate or long disease duration, anti-TNF agents are recommended for patients who have not responded to methotrexate treatment.
    • Abatacept and Rituximab are recommended only for patients who had moderate to high disease activity, poor prognostic features and an inadequate response to methotrexate in combination with other DMARDs or failed to respond to sequential treatment with other DMARDs.
    • Combinations of biologic agents are not recommended because of the higher incidence of adverse events and/or lack of added efficacy.
    • Active bacterial infection, active herpes zoster viral infection, active or latent tuberculosis or acute or chronic hepatitis B and C are all contraindication to initiation or resumption of DMARD use.
    • Influenza and pneumococcal vaccines are generally recommended, as well as hepatitis B vaccine if patient is at risk.
    • Heart failure, lymphoma, multiple sclerosis or demyelinating disorders are contraindications for the use of anti-TNF agents.
    • Women who are planning for pregnancy, pregnant or breastfeeding should not use methotrexate, minocycline or leflunomide. 

    For more information on the new guidelines, see this article from the American College of Rheumatology.

Published On: July 05, 2008