New Guidelines Focus on Early RA Treatment

As a response to the rapidly changing world of rheumatoid arthritis treatment, the American College of Rheumatology (ACR) has issued an update to its recommendations, focusing on early treatment, screening for tuberculosis, and special considerations for high-risk patients.

Writing in the May Arthritis Care & Research, the guideline authors, led by Jasvinder A. Singh, MBBS, of the University of Alabama at Birmingham, re-emphasized the importance of more aggressive treatment in early disease per the 2008 guidelines.

They summarized their reasoning for this shift in approach as follows:

Better outcomes can be expected with earlier intervention
Joint damage is permanent once it occurs, so prevention is crucial
Intensive treatment can help patients maintain physical function and quality of life

However, they pointed out that most of the recommendations are based on level C evidence, combining data from the literature and expert opinion.

Disease Activity

A main point of the recommendations is that the goal of early treatment today is remission or at least low disease activity. For patients who have been symptomatic for 6 months or less, the usual approach is monotherapy with a disease-modifying anti-rheumatic drug (DMARD), such as methotrexate.

Monotherapy is recommended whether disease activity is low, moderate, or high if no poor prognostic factors, such as extra-articular disease or bony erosions, are present.

However, if disease activity is moderate or high and poor prognostic factors are present, combination DMARD therapy can be tried, adding a drug such as hydroxychloroquine.

And if disease activity is high in early disease and the prognosis is poor, an anti-tumor necrosis factor (TNF) biologic agent can be tried in combination with methotrexate or alone.

When Patients Fail to Respond

The recommendations next addressed treatment strategies for established disease of 6 months or more duration, when patients fail to respond, deteriorate, or are unable to tolerate treatment.

Patients who have been on anti-TNF therapy for 3 months and have shown no response or a loss of benefit can be switched either to another anti-TNF agent or to a non-TNF biologic drug.

Those who have been on a non-TNF biologic for 6 months and have had inadequate response, or loss of effect, can be switched to a TNF or non-TNF biologic.

The reason for waiting 6 months with a non-TNF agent is that efficacy may take longer with these drugs, the authors explained.

Patients with high disease activity considered to have failed TNF treatment because of serious adverse events should be switched to a non-TNF biologic, but if the adverse event was not considered to be serious, either another anti-TNF agent or a non-TNF biologic can be used.