2021 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis
(Part 8)
Let us continue our series of discussions on the treatment of rheumatoid arthritis (RA) as recommended by the American College of Rheumatology (ACR).
The use of conventional synthetic Disease Modifying Anti-Rheumatism Drugs (csDMARDS) is conditionally recommended over addition of a biologic DMARD (bDMARD) or targeted synthetic DMARD (tsDMARD) for patients with a serious infection within the previous 12 months, and those who have moderate-to-high disease activity despite using csDMARD monotherapy.
This recommendation is made based on some data indicating a lower risk of infection linked with a combination of csDMARDs, which is either dual or triple therapy, compared to bDMARDs or tsDMARDs.
Some health care experts may choose csDMARDs even if the infection happened 12 months prior to a change in medication.
The addition of or switching to DMARDs may be recommended under certain conditions over dose escalation of glucocorticoids for patients with an infection within the previous 12 months, and also have moderate-to-high disease activity.
This recommendation is based on some studies suggesting a solid link between dose and duration of use of glucocorticoids.
Nontuberculous mycobacterial (NTM) lung disease is something that should be taken care of when using treatments for RA.
Given the variability of NTM lung disease problems and response to treatment, patients should be closely managed with an infectious disease specialist or pulmonologist.
It is best to use the lowest possible dose of glucocorticoids (discontinuation if possible) as recommended with conditions over continued use of glucocorticoids without dose adjustments for patients with NTM.
This is based on data suggesting a heightened risk of NTM in some patients getting either inhaled or oral glucocorticoids.
The use of csDMARDs is recommended in certain conditions over the use of a bDMARD or tsDMARD for patients with NTM, and also have moderate-to-high disease activity despite csDMARD monotherapy use.
This is based on the lower risk of NTM linked with csDMARDs compared to bDMARDs and tsDMARDs.
Abatacept is recommended in certain conditions over other bDMARDs and tsDMARDs for patients with NTM who have moderate-to-high disease activity despite csDMARDs use.
Abatacept is recommended over other bDMARDs and tsDMARDs based on data from studies on tuberculosis. There is uncertainty about the risk of mycobacterial infections associated with non–tumor necrosis factor (TNF) inhibitor bDMARDs and tsDMARDs.
TNF inhibitors are linked with heightened rates of mycobacterial infections and should be avoided.
We will discuss other recommendations that should be used in caution due to low evidence certainty as we continue our discussion next week.