Physicians who treat patients with arthritis and related conditions now have more help in selecting treatments, thanks to a growing library of new and updated clinical guidelines and recommendations.
When faced with both common and uncommon situations, unanswered questions or complicated cases, guidelines and recommendations can provide physicians with answers without the need to personally do exhaustive searches of the medical literature, says Michael Ward, MD, an investigator for the National Institutes of Health.
Guidelines are not meant to replace the judgment of a knowledgeable physician or the preferences of a patient, says Dr. Ward.
“The [American College of Rheumatology] makes the point that these are not requirements, but need to be judged in the context of each individual patient, because each individual patient is different, has a different medical history, has different comorbidities or different contraindications to particular treatments, and all of that needs to be factored in when deciding on any particular course of action,” says Dr. Ward, who was principal investigator for new recommendations for the treatment of ankylosing spondylitis and non-radiographic axial spondyloarthritis.
His group’s document is among several new or updated guidelines that were published recently. Here’s a summary:
Ankylosing Spondylitis and Non-radiographic Axial Spondyloarthritis
A joint project of the ACR, the Spondylitis Association of America and the Spondyloarthritis Research and Treatment Network, this first-ever set of recommendations covers drug and non-drug treatments, patient monitoring, the management of patients with related conditions, and the appropriateness of certain surgeries.
The inclusion of recently approved therapies – including an oral immune modulator and an injected biologic – is one of the biggest differences between the psoriatic arthritis guidelines published January 2016 and previous guidelines published in 2009, says Alexis R. Ogdie-Beatty, MD, director of the Penn Psoriatic Arthritis Clinic at the University of Pennsylvania, Philadelphia and a member of the steering committee of The Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA), which developed the guidelines.
A significant body of literature that has developed about outcomes in psoriasis and psoriatic arthritis has also led to changes in the GRAPPA “grid” for assessing disease activity and selecting a therapy, says Dr. Ogdie-Beatty. “Finally, we added recommendations regarding screening for comorbidities among patients with PsA and how treatment selection may be affected by the presence of individual comorbidities,” she says.
New recommendations for polymyalgia rheumatica (PMR) developed by the ACR and European League Against Rheumatism address both treatments to use – corticosteroids and methotrexate – and ones to avoid (TNF inhibitors and the Chinese herbal preparations Yanghe and Biqi).
Because of the importance of corticosteroids in the treatment of PMR, a significant part of the recommendations focus on the dosage of corticosteroids as well as when and how to taper them.
The guidelines also feature recommendations on establishing a diagnosis, assessing comorbidities, monitoring for complications, and determining frequency of follow-up visits.
First-ever guidelines for Sjögren’s syndrome developed by the Sjögren’s Syndrome Foundation provide guidance for treating the effects of dryness of the eyes and mouth as well as the systemic effects of the disease.
For dry mouth, the guidelines call for topical fluoride use in all patients along with treatment to improve saliva flow. For dry eyes, the guidelines recommend corneal exams to determine the cause of dryness and offer recommendations of non-drug treatments based on the nature and severity of the problem. For severe systemic Sjögren’s, rituximab (Rituxan) is the first line of treatment and the only biologic recommended.
Just three years after the publication of its 2012 guidelines, the ACR published updated guidelines for the treatment of rheumatoid arthritis because of the rapid accrual of evidence and new therapies, advances in guideline development methodology, and the need to broaden the scope of previous recommendations, says Kenneth Sagg, MD, a rheumatologist at the University of Alabama at Birmingham and guidelines author.
The guidelines include new therapies, new approaches to the use of older therapies, and some new topics such as recommendations around the use of corticosteroids, Dr. Saag says.
Major topics addressed include medication tapering, the use of biologics and DMARDs in high-risk populations, the use of vaccines in patients receiving DMARDs or biologics, and screening for tuberculosis in people starting DMARDs.
Author: Mary Anne Dunkin for the Arthritis Foundation