American College of Rheumatology Issues New Guidelines for the Treatment of Rheumatoid Arthritis

In 2008, the American College of Rheumatology (ACR) issued new guidelines for the use of nonbiologic and biologic disease-modifying antirheumatic drugs (DMARDs) in treating rheumatoid arthritis (RA).¹ These guidelines represent the first time the ACR developed recommendations for the use of biologic agents and are the first update on the use of nonbiologic DMARDs since 2002. The nonbiologic agents covered in the guidelines include hydroxychloroquine, leflunomide, methotrexate, minocycline, and sulfasalazine; the biologic agents addressed were abatacept, adalimumab, etanercept, infliximab, and rituximab.

The ACR guidelines include a number of treatment algorithms, with separate scenarios for biologic versus nonbiologic DMARDs. Treatment-recommendation algorithms take into consideration RA disease characteristics such as disease duration, severity, and prognostic markers. The ACR recognizes 3 distinct disease durations: less than 6 months, 6 to 24 months, and more than 24 months. The recommendations require determination of disease activity (ie, low, moderate, or high) based on one of six instruments: Disease Activity Score in 28 joints, Simplified Disease Activity Index, Clinical Disease Activity Index, Rheumatoid Arthritis Disease Activity Index, Patient Activity Scale (PAS) or PASII, or the Routine Assessment Patient Index Data. Treatment guidelines also differ based on the presence or absence of prognostic markers including functional limitation, extra-articular disease, rheumatoid factor positivity, positive anti-cyclic citrullinated peptide antibodies, or bony erosions by radiography.

In addition to the treatment algorithms, the ACR guidelines also list contraindications to starting or resuming therapy with nonbiologic and biologic DMARDs in RA patients. Clinicians are also provided with guidelines regarding baseline evaluations and vaccines for starting a given therapy. Particular attention regarding tuberculosis screening for patients receiving biologic DMARDs is also provided.

As with all treatment guidelines, the ACR recommendations do not replace individualized treatment decisions but provide clinicians with evidence-based guidance regarding the use of DMARDs in patients with RA.

Practice Points

• The ACR published new recommendations regarding the use of biologic and nonbiologic disease-modifying antirheumatic drugs for rheumatoid arthritis treatment
• New treatment recommendations are grouped by disease duration, disease activity, and the presence or absence of markers of prognosis

Reference

1. Saag KG, Teng GG, Patkar NM, et al. American College of Rheumatology 2008 recommendations for the use of nonbiologic and biologic disease-modifying antirheumatic drugs in rheumatoid arthritis. Arthritis Rheum. 2008;59:762-784.