2021 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis
(Part 7)
Let’s continue with our discussion on the use of Disease Modifying Anti-Rheumatism Drugs (DMARDS)
The use of a biologic DMARD (bDMARD) or targetted synthetic DMARD (tsDMARD) is recommended with certain conditions over triple therapy, which means the addition of sulfasalazine and hydroxychloroquine for patients using maximum allowed doses of methotrexate.
The expert panel of the American College of Rheumatism engaged in vigorous debate whether or not to recommend addition of a bDMARD or tsDMARD as against the use of sulfasalazine and hydroxychloroquine for patients who are not responding well with
methotrexate monotherapy.
The additional use of bDMARD or tsDMARD was ultimately chosen by the expert panel because the patient panel wants to maximize the improvement from Rheumatoid Arthritis as quickly as possible.
Moreover, both the patient and expert panels valued the efficacy of methotrexate plus a bDMARD or tsDMARD.
We need to consider that recommendations should be considered as conditional since some patients with co-morbidities should be given other forms of therapy given to risks.
The risks involved with co-morbid patients should be considered when assessing the case and include patient choices. It is important to take a look at this when treating rheumatoid arthritis (RA).
On the other hand, the use of a bDMARD or tsDMARD of a different class may be considered/reconsidered for certain patients.
The recommendation is considered to be conditional considering the patient and doctor’s choice are likely to vary based on prior experiences with a certain DMARDs.
The use of glucocorticoids can be considered in addition of/switching to DMARDs is recommended with condition over use of glucocorticoids for certain patients.
The assumption here is there should be improved disease control with the use of DMARDs thus allowing decreased use of glucocorticoids.
This is a conditional recommendation as glucocorticoids use may be required for some patients not responding well with DMARDs.
Using DMARDs is recommended conditionally over intraarticular (IA) glucocorticoids for certain patients.
This premise is based on the thought DMARDs should be adjusted to reduce disease activity, regardless of treatment with IA glucocorticoids.
Patients may choose to defer adding/switching DMARDs if they are able to get some relief using IA injections.
We continue our series on the treatment guidelines for RA in our column next week.