ACR RA guidelines ‘push the needle away’ from glucocorticoids as primary option
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Glucocorticoids should no longer be the “default” option for many patients with rheumatoid arthritis, according to authors of a new recommendation document presented at ACR Convergence 2020.
Bryant England, MD, PhD, of the University of Nebraska Medical Center, provided an overview of the guideline development process.
Because of the emergence of three new studies and a raft of new data, “it became imperative that the ACR update these treatment guidelines again,” England said.
The process was first to define the scope of the project and then create teams, including a core leadership team that overviewed the project “from inception to completion,” a literature review team, a voting panel, a patient panel comprised of 10 individuals with RA, an expert panel comprised of people with particular expertise on various aspects of the process and ACR staff to oversee administrative concerns, according to England.
With the teams in place, the next step was to develop Population- Intervention- Comparator- Outcomes questions. The team ended up with “81 clinically relevant PICO questions,” according to England.
The PICO questions led to a project plan to be made available and reviewed by the public. After that came a comprehensive literature review, with evidence considered in conjunction with clinical expertise and experience.
“Nearly 23,000 articles were identified initially,” England said. After narrowing them down to those involving pharmacologic interventions and further paring them down based on relevance or quality of the study, the team arrived at 133 studies that were “mapped to at least one clinically relevant question.”
However, England acknowledged the dearth of evidence on which the group ultimately had to make recommendations. “There was no evidence found for 41% of the clinically relevant PICO questions,” he said.
At the moment, the document is under peer review by the ACR. It contains 44 recommendations, seven of which are strong and 37 of which are conditional. Recommendations are made for direction — meaning, for or against. Conditional recommendations are made when there is “less certainty about balance of benefit and risk,” England said.
“These recommendations are intended for the general RA patient, not the exception,” England said.
Strong recommendations
Regarding those recommendations, Liana Fraenkel, MD, MPH, director of patient centered population health services at Berkshire Health Systems, said that they will apply to specific RA populations and topics, including: DMARD-naïve patients with low and moderate to high disease activity; the administration of methotrexate; therapies for patients not at target; tapering of medications when possible; and certain specific populations.
“The objective of the panel was to change the default for clinicians, that the norm should be to always prescribe prednisone, even as a bridge,” Fraenkel said. “The underlying theme was a strong push to use methotrexate before going on to other DMARDs.”
In moving away from steroids, Fraenkel noted that “even lower doses of prednisone can be harmful.” In addition, the patient panel stressed that tapering of prednisone is challenging.
Regarding the caution with biologics and biosimilars, Fraenkel cited the “relative lack of long-term experience” with these drugs as the motivating factor.
Zeroing in on the points with the highest level of evidence, methotrexate is strongly recommended over hydroxychloroquine or sulfasalazine, and strongly recommended over biologic or targeted synthetic DMARD monotherapy.
In looking at DMARD monotherapy compared with combination approaches, methotrexate monotherapy, again, is strongly recommended over hydroxychloroquine or sulfasalazine. Methotrexate monotherapy is also strongly preferred compared with methotrexate plus a non-TNF inhibitor biologic or a traditional synthetic DMARD.
Regarding the mitigation of glucocorticoids, DMARDS without longer-term glucocorticoid therapy — defined by a 3-month boundary — is strongly recommended over DMARDs plus longer-term steroids.
With regard to meeting treatment goals, a treat to target strategy is strongly recommended over usual care if the patient is naïve to biologics and traditional synthetic DMARDS.
Other recommendations
In patients with low disease activity, hydroxychloroquine is conditionally recommended over other conventional synthetic DMARDS, sulfasalazine is conditionally recommended over methotrexate and methotrexate is conditionally recommended over leflunomide.
Regarding the administration of methotrexate, oral formulations are conditionally preferable to subcutaneous injection. However, if oral methotrexate is not tolerated, splitting the dose with a subcutaneous injection or an increase in folic acid is conditionally recommended over a switch to a new DMARD, according to Fraenkel.
Looking closer at glucocorticoids, a conditional recommendation has been made to add or switch to DMARDs for patients to remain at target. In general, Fraenkel suggested that “changing the default” from prednisone was critical to meeting treatment goals and satisfying patient desires. “We wanted to push the needle the other way away from glucocorticoids,” she said.
If there is one more broad theme of the document, it pertains to tapering medications. While continuation of all DMARDs at current dose is conditionally recommended over dose reduction, dose reduction is conditionally recommended over gradual discontinuation, and gradual discontinuation is conditionally recommended over abruptly stopping therapy.
But there is one key consideration pertaining to tapering and discontinuation, according to Fraenkel. “Tapering should only be considered in patients who have been at target for over 6 months,” she said.
Finally, Fraenkel encouraged attendees to review the document for guidance in special populations, including patients with pulmonary disease, heart failure, lymphoproliferative disorders, hepatitis B, non-alcoholic fatty live disease, persistent hypogammaglobulinemia without infection or nontuberculous mycobacterial lung disease.
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England B, Fraenkel L. New ACR Recommendations for the Management of Rheumatoid Arthritis. Presented at: ACR Convergence 2020; November 5-9, 2020 (virtual meeting).
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