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Treatment Guidelines in Rheumatology: What Do You Hear When One Hand Claps?
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We are privileged to have with us this month an esteemed panel of experts in the psoriatic arthritis space: M. Elaine Husni, MD, MPH, director of the Arthritis Center at Cleveland Clinic; Philip J. Mease, MD, from the University of Washington School of Medicine; Jasvinder Singh, MD, professor at the University of Alabama in Birmingham; and Dafna Gladman, MD, rheumatology professor of medicine at University of Toronto and member of the National Psoriasis Foundation medical board.
These experts have shared with us their perspectives on recently released PsA treatment guidelines, which they each helped develop. I have read the guidelines, and as with all such efforts, I am both humbled by the process of their production and welcoming of their publication as I search for ways they may help me care for patients with this formidable disease.
Calabrese
At the same time, having had the opportunity to read and digest many guidelines and/or recommendations on everything from managing ANCA disease to how patients with psoriasis should eat, I always have a nagging feeling after I am done. I seem to hear a little voice from somewhere asking me “OK, well now what should I do with these?” This seems odd given that I have actually participated in guideline and recommendation deliberations in the past and I still seem to get stuck with sorting out their utility.
We all know the difference between opinion- and data-driven guidelines. Thankfully, we can all be assured that the newly released PsA treatment guidelines are solidly evidenced-based. Opinion-driven documents are often referred to as the basis for eminence-based medicine whereas rigorous efforts such as the PsA guidelines, which utilize techniques such as GRADE methodology, are considered to be based on hardcore science. Yes, if life was only that simple — I say this because there is a tradeoff.
While rigorous method is more scientifically-based, its application is sorely limited by its design. For example, to provide a guideline, a PICO (Population/Intervention/Comparison-Control/Outcome) question must be answerable, meaning there must be data and thus have actually been studied. Unfortunately, so many times, our patients have problems that just have never been studied. These patients neither present nor ask us PICO questions, but actual patient questions!
I recognize there have been no RCTs on basic exercise guidelines for people with PsA (and for that matter, most type of IMIDS) but to tell providers that there is low-level evidence for recommending any exercise over no exercise (with a caveat for acute inflammatory states) just doesn’t hold water and diminishes the practicality and veracity of such guidelines. Even the moderate level of evidence for smoking cessation seems silly.
We as a profession know that, of course, we should be dedicated to tobacco prevention and cessation efforts. The separate NPF guidelines on dietary interventions for psoriasis are even more detached from reality in that they recommend hypocaloric diets for obese psoriatic patients, most of whom have metabolic syndrome. I am sorry, but that is not the type of wellness patient education that has either face or content validity in my mind.
The bottom line is that guidelines such as these, in reality, represent what I like to think of as the astral 95% confidence limits of how we should treat people. To reach the remainder of the population we often seek and utilize eminence-based medicine combined with our own common sense. My use of Zen kan in the title is not a joke: In order to actually care for patients you need both hands, representing the practical opinion of experts combined with your own experience, as well as scientifically generated guidelines such as we now have for PsA.
I will end with two quotes for you to ponder as you read these new guidelines. I think these should be invoked and puzzled over, perhaps with a glass of fine Barolo or hot tea every time any of us read a newly released set of guidelines.
“Believe nothing — no matter where you read it or who has said it, not even if I have said it, unless it agrees with your own reason and your own common sense.” – Buddha
“At the heart of science are questions — not facts.” – Professor Michael Kennedy
Please send me your take at calabrl@ccf.org or through Twitter @LCalabreseDO.
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- Leonard H. Calabrese, DO, is the Chief Medical Editor, Healio Rheumatology, and Professor of Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, and RJ Fasenmyer Chair of Clinical Immunology at the Cleveland Clinic.
Disclosure: Calabrese reports serving as an investigator and a consultant to Horizon Pharmaceuticals.