Cath Lab Digest

Chicago—New recommendations for the treatment of rheumatoid arthritis (RA) are near completion and will provide evidence-based recommendations on a number of issues related to the use of biologics and traditional disease-modifying antirheumatic drugs (DMARDs).These include indications for the use of each class of medications, switching agents (with particular emphasis on biologics), tuberculosis screening, vaccinations, and the use of biologics in high-risk patients.

Jasvinder Singh, MBBS, associate professor of medicine, University of Alabama at Birmingham, presented data on the 2011 update of the 2008 American College of Rheumatology (ACR) recommendations for the treatment of RA at the ACR meeting. The final guidelines will be published this summer in Arthritis Care & Research, according to an ACR spokeswoman.

Along with providing a preview of specific recommendations in the update, Dr. Singh discussed the process used to develop the guidelines.

Development of the Guidelines

As with all guidelines, the quality of evidence on which they are based is critical to ensuring the recommendations represent the best available data. The task force formed to develop the guidelines used the RAND/UCLA method, which, according to Dr. Singh, is one of the most methodologically studied expert panel processes in healthcare. Along with using data from a systematic review of the literature to generate the best evidence, the method also incorporates clinical scenarios that represent a considerable spectrum of hypothetical patients requiring treatment-related decisions.

The task force relied on a team of experts to review the evidence from the literature review, which included 149 studies, as well as the clinical scenarios created by the task force. Dr. Singh emphasized that the clinical scenarios were based on common clinical situations (and not exceptional situations) that clinicians face. Each clinical scenario posed a question regarding diagnosis or treatment of a patient given specific variables (disease duration or activity, DMARD failure, features of poor prognosis, or treatment duration) and factors weighed when considering treatment (low–high disease activity, early or late duration, failure or nonfailure of DMARD, presence or absence of poor prognostic features, and length of treatment).

Expert review of the clinical scenarios proved the reproducibility of decision-making among different panels of experts, said Dr. Singh.

Preview of 2011 Recommendations on the Use of Biologics and DMARDs

Emphasizing that these guidelines are meant to be advisory and not prescriptive, Dr. Singh discussed several updates in the 2011 guidelines. One of the main objectives of the new guidelines was to construct evidence-based recommendations on the use of biologics and traditional DMARDs in patients with both early and established RA. For both early and established RA, the 2011 task force recommended setting the target for disease activity as either remission or low disease activity (see Sidebar 1 and Sidebar 2).

Dr. Singh also summarized the recommendations for using biologics in patients who have been treated for a malignancy and for those with other medical conditions.