2021 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis
(Part 9)
We now reach the conclusion of our discussion on the guidelinesof the American College of Rheumatology (ACR) on rheumatoidarthritis (RA).
The ACR guidelines were developed to provide clinicians with recommendations to help them make decisions related to treatment that is frequently faced in their respective practice.
The updates now include recommendations for administration of methotrexate, use of methotrexate in patients with subcutaneous nodules, pulmonary disease, and non alcoholic fatty liver disease.
The use of rituximab in patients with hypogammaglobulinemia, is likely considered for treatment of patients of RA with Nontuberculous mycobacterial (NTM) lung disease.
This set of recommendations is for those with hepatitis C and solid malignancies. The expert panel did not discuss on specific recommendations for patients with hepatitis C because curative antiviral therapy is now widely available.
The expert panel did deliberate over questions related to use of Disease Modifying Anti-Rheumatism Drugs (DMARDs ) in patients with solid malignancies. However, given the need of personalized treatments for some patients, the experts felt that a general recommendation was not feasible.
In Feb. 2021, the Food and Drug Administration of the United States (FDA) came up with a Drug Safety Alert noting a possible risk of major cardiovascular problems and malignancies.
This is excluding non-melanoma skin cancer in patients with RA, older than 50 years old and with at least 1 risk factor for cardiovascular disease. The warning was aired to those who were participating in a randomized controlled trial designed to compare the safety of tofacitinib to adalimumab.
This will result in the ACR recommendations review once peer-reviewed results are published.
The fast evolving comparative effectiveness and safety signals linked with Janus Kinase (JAK) inhibitors puts into fore the need to move towards a shared decision-making process when tweaking the use of DMARDs.
Moreover, previous recommendations showed caution against the use of tumor necrosis factor (TNF) inhibitors in patients with skin cancer; the results of published studies examining specific DMARD-related risks of non-melanoma skin cancer and melanoma do not provide definite recommended use for or against certain DMARDs.
The expert panel also considered some questions related to the use of checkpoint inhibitor therapy, but the certainty of current practice patterns and differences in treatment for specific cancer types are affected in the development for patients who are receiving checkpoint inhibitor therapy.
It is anticipated that there could be additional guidelines for patients suffering systemic rheumatic diseases and some malignancies. This is going to be developed as additional data will become available.
It is expected that additional data may modify the direction and/or strength of specific recommendations. The ACR will update the recommendations and answer these and other questions as new data are published.