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New RA therapy recommendations cover 5 domains

New RA therapy recommendations cover 5 domains

Most patients with a confirmed diagnosis of rheumatoid arthritis (RA) use nonbiologic disease-modifying antirheumatic drugs (DMARDs), and the rate of biologic DMARD use is increasing rapidly, according to the American College of Rheumatology (ACR).The organization last updated recommendations for the use of nonbiologic DMARDs in 2002 and had not developed recommendations for using biologic agents. Recently, however, the ACR issued new and revised recommendations that address the use of both types of therapies in patients with RA when they are starting or resuming them.

A Core Expert Panel of clinicians and methodologists used an evidence- based approach with an extensive literature review in guiding development of the recommendations for the use of DMARDs in RA. The ACR prespecified the following 5 key areas of therapy: (1) indications for use, (2) screening for tuberculosis, (3) monitoring for adverse effects, (4) assessing the clinical response, and (5) the roles of cost and patient preference in decision making. Also considered were disease duration, disease severity, and prognostic features.

The ACR's 2008 recommendations for the use of nonbiologic and biologic DMARDs in RA include the following:
Patients with all disease durations and all degrees of disease activity start with methotrexate (MTX) or leflunomide therapy, regardless of prognostic features.
Patients without poor prognostic features, with low disease activity, and with disease duration of 24 months or less or short disease duration use hydroxychloroquine (HCQ) or minocycline, respectively.
Patients with all disease durations and all degrees of disease activity but with poor prognostic features use sulfasalazine (SSZ).
Patients with moderate to high disease activity use MTX plus HCQ, regardless of disease duration or poor prognostic features; patients with various disease durations and prognostic features use other dual-DMARD combinations.
Patients with poor prognostic features and moderate to high levels of disease activity, regardless of disease duration, use a triple-DMARD combination (MTX plus HCQ plus SSZ).
Only patients with early RA (duration of less than 3 months) who have high disease activity and never received DMARDs use an anti–tumor necrosis factor α (anti–TNF-α) agent—etanercept, infliximab, or adalimumab—with MTX.
Patients with intermediate- and longer-term RA for whom previous MTX monotherapy led to an inadequate response and who have moderate disease activity and features of a poor prognosis, as well as patients with high disease activity, irrespective of prognostic features, use anti–TNF-α agents.
Patients with at least moderate disease activity and a poor prognosis for whom MTX in combination with DMARDs or sequential administration of other nonbiologic DMARDs led to an inadequate response use abatacept.
Patients with high disease activity and a poor prognosis for whom MTX in combination with DMARDs or sequential administration of other nonbiologic DMARDs led to an inadequate response use rituximab.

In addition, the ACR recommended against initiating or resuming treatment with MTX, leflunomide, or biologic agents for patients with RA who have active bacterial infection, active herpes zoster viral infection, active or latent tuberculosis, or acute or chronic hepatitis B or C. Contraindications to DMARD use also included severe upper respiratory tract infections, previous lymphoproliferative disease, moderate or severe heart failure, multiple sclerosis or demyelinating disorders, and pregnancy.

The investigators noted that the recommendations are intended to help guide therapy rather than proscribe appropriate therapies and that applying them to clinical practice will require individualized patient assessment and clinical decision making. They are described as extensive but not comprehensive, and they will be updated regularly.

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