2021 Rheumatoid Arthritis Treatment Guidelines
Dr. Sparks: I'm going to give a very brief summary of the 2021 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis. I'll mention I was a co-author on this initiative, and certainly there's a lot to digest, and I'm just going to give a few things that are particularly pertinent to treating clinicians for patients with rheumatoid arthritis. I think the thing that this went into great detail about is how to manage initial therapy for the vast majority of patients. That would be methotrexate. So, these guidelines went into a lot of detail about when methotrexate should be started, how it should be started with folic acid supplementation PO versus subQ.
Methotrexate with folic acid supplementation as preferred treatment
The bottom line is that probably for the vast majority of patients who have moderate or severe rheumatoid arthritis, methotrexate is the preferred agent as monotherapy, preferred with folic acid supplementation, and either PO or subcutaneous are acceptable. I'd say for the most part, patients, at least adult patients, prefer PO formulation. There is a subset of patients who have relatively mild rheumatoid arthritis with low disease activity who might benefit from hydroxychloroquine as an initial DMARD. If patients have reluctance to use methotrexate or contraindications, other conventional synthetic DMARDs such as sulfasalazine or leflunomide could also be considered.
Glucocorticoids should be the exception, not the rule
Probably one of the most talked about items of the new ACR guidelines for RA treatment is how corticosteroids should be used. Certainly, corticosteroids have been used for decades in rheumatoid arthritis and remain an important adjunct to therapy. But certainly, too many of our patients end up on corticosteroids long term and are at risk of all of the adverse events that we know can come with glucocorticoids. So, the ACR actually took a pretty bold strategy of actually conditionally recommending against glucocorticoid use as the default therapy for bridge therapy while DMARDs kick in.
This is not to say that this should not be used. It's rather that the paradigm should be that the use of glucocorticoid should be the exception and not the rule. Having said that, many patients might really respond quickly to glucocorticoids and might prefer after risk-benefit discussion with their clinician to start that. Having said that, many of these patients end up on these medications for many months or even years. So, I think it is a great initiative to try to limit the number of patients who get started on glucocorticoids because you can become a long-term user if you weren't a short-term user.
TNF inhibitor for patients refractory or intolerant to methotrexate
Other themes of the guidelines were related to advanced therapies, biologic or targeted synthetic DMARDs. Interestingly, at the very tail end of the process is when the seminal ORAL surveillance study results came out that showed a possible increase in cardiovascular and cancer risk of tofacitinib versus TNF inhibitor. So, luckily, we were able to broach that in the guidelines, though certainly there's going to be a lot more written about that. The bottom line is that the guidelines for the most part would recommend a TNF inhibitor as the initial biologic DMARD for patients with rheumatoid arthritis who are refractory or intolerant to methotrexate.
As far as what happens for patients who fail initial TNF, it's really a shared decision process related to all the different other options, which would include triple therapy, but would also include switching to a different mechanism of action, switching to a JAK inhibitor, or cycling to a second TNF in particular for patients who had secondary non-response to TNF after initial response. So, these are the major points of the ACR 2021 treatment guidelines for rheumatoid arthritis. Again, I would encourage you to read them in more detail. Particularly, they also broached how comorbidities should be thought of, in particular lung disease. So, hopefully, that will help give you at least some major points about how to think about treatment of RA in the contemporary age.
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