As-yet unpublished RA guidelines exhibit 'puzzling' conditional recommendations
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While many of the forthcoming American College of Rheumatology guidelines for rheumatoid arthritis capture the reality of clinical practice, some recommendations are “puzzling,” according to a speaker at the ACR State-of-the-Art Clinical Symposium.
It is important to note that many of the recommendations are ‘conditional’ because they are based on little or no data, according to presenter James R. O’Dell, MD, Stokes Shackleford Professor and chief of the division of rheumatology at the University of Nebraska and Omaha VA Medical Center.
It is with this in mind that O’Dell offered a recommendation of his own: “Clinical judgment should always dictate what the guidelines say,” he said.
With that, O’Dell reviewed a handful of broad categories addressed in the preliminary presentation on the guidelines from the ACR Convergence 2020. Those included recommendations for use of disease-modifying anti-rheumatic drugs in treatment-naïve patients with high- and low-disease activity; the use of methotrexate; treating to target; tapering of medications; and for specific populations that many clinicians “struggle with in the clinic,” according to O’Dell. “Many of these recommendations are going to be very helpful to us in our practice.”
O’Dell “strongly” endorses the recommendation to start with methotrexate in DMARD-naïve patients with high-disease activity. “Methotrexate is king,” he said. “It should be the foundation of all of our treatments in RA.”
While O’Dell acknowledged that tolerability can be an issue with methotrexate, he stressed that folic acid can be useful in this regard. “It is clearly the best DMARD we have,” he said. “When we forget that, it is a peril to us and our patients.”
Turning to DMARD-naïve patients with low-disease activity, O’Dell highlighted the conditional recommendation for hydroxychloroquine. “Many clinicians have forgotten about or ignored hydroxychloroquine,” he said. “It is the best drug we have in terms of side effects. It lowers cholesterol and lowers diabetes risk. All these things are really important to our patients.”
As for the administration route of methotrexate, O’Dell did find it “puzzling” that the oral formulation is recommended over subcutaneous in the first line. “I applaud them for tackling this,” he said, but noted that he believes patient voices on the guideline panel may have added weight to the recommendation for oral administration. He suggested that, in terms of efficacy, it is “no contest” that subcutaneous methotrexate is superior to oral.
If O’Dell had another concern with the guideline, it is that dosing or duration of methotrexate are not adequately addressed. “These [clinical decisions] are critically important,” he said.
While O’Dell understands caution from the panel for long-term steroid use, he is less certain about the panel’s caution about short-term steroid use. He believes that short-term steroids can be both safe and effective in certain patient populations.
Also “puzzling” to O’Dell was the panel’s position that there are certain situations in which a treat-to-target strategy should not be used. “We should be doing this every step of the way,” he said.
That said, O’Dell supports the conditional recommendation to treat to low-disease activity, as opposed to remission, in some cases. “This gets us off the hook, because many of our patients do not achieve remission,” he said. “Of course, we should aim for remission, but we should be allowed to use clinical judgment” when that may not be feasible.
Also of concern for O’Dell is the panel’s recommendation against tapering or reduced dosing. “The majority of our patients will continue to do well, as long as you taper gradually,” he said. “I support tapering. That is why this recommendation is puzzling to me.”
As for challenging patient populations, O’Dell felt “reassurance” that the panel conditionally recommended methotrexate in patients with subcutaneous nodules.
In addition, the conditional recommendation for methotrexate in pulmonary disease is a good one, according to O’Dell. “We used to think methotrexate causes interstitial fibrosis, but there are no data to support that,” he said.
A non-TNF biologic, such as a JAK inhibitor, is recommended in patients with class III or IV heart failure, according to O’Dell. “Based on the data, I think that is a reasonable recommendation,” he said.
In patients with lymphoproliferative disorders, which O’Dell noted are “over-represented” in rheumatic disease populations, rituximab (Rituxan, Genentech) is “an excellent way to go.”
For patients with serious infections, O’Dell supports the recommendation to add a conventional DMARD as opposed to a biologic. “Clearly, infections are increased with biologics,” he said.
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O’Dell JR. RA Management: Current Guidelines and More. Presented at: American College of Rheumatology State-of-the-Art Clinical Symposium. April 9-11, 2021 (virtual meeting).
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