Rheumatoid arthritis

ACR guidelines for RA call for more aggressive use of MTX


New American College of Rheumatology 2020 guidelines for managing rheumatoid arthritis will advise clinicians to be more aggressive with the use of methotrexate.

Speaking in a press conference at the ACR 2020 Convergence annual meeting, guideline author Dr Liana Fraenkel  said the “strong emphasis” on use of methotrexate was a notable difference from the last update in 2015.

The soon to be published guidelines recommend starting patients on methotrexate and continuing with the treatment instead of rapidly switching to another disease-modifying anti-rheumatic drug (DMARD).

“We offer rheumatologists guidance on the nuances of how to really maximize the use of methotrexate in these patients,” said Dr Fraenkel, an Adjunct Professor of Rheumatology at Yale University School of Medicine.

“There is a strong emphasis on using methotrexate and maximising methotrexate before adding or switching to a biologic or JAK inhibitor.”

Other differences in the updated guidelines include scrapping the recommendation to escalate to triple therapy before starting a biologic.

“Now, we recommend that rheumatologists add a biologic or a targeted synthetic DMARD instead of switching patients to triple therapy,” she said.

The update also stresses the importance of minimising the use of glucocorticoids, gives specific advice on drug tapering and includes populations not previously covered by the guidelines such as patients with pulmonary disease, non-alcoholic fatty liver disease, and persistent hypogammaglobulinaemia.

Other separate guidelines are expected soon on the on non-pharmacologic management of rheumatoid arthritis and vaccine recommendations.

Dr Fraenkel said rheumatoid arthritis patients were heavily involved in the guideline process and were key to some of the recommendations such as the shift from triple therapy to biologics.

“There was very vigorous debate over this issue. This wasn’t an easy recommendation to come by. The rationale for this really came from patients. The onset of action was really what drove this difference.”

What was notable in the guideline process was the lack of evidence for making clinical recommendations.

“I think we’ve laid out a very strong research agenda. We really need trials to address clinically important questions that are driven by patients and not simply driven by ‘we have a new molecule to test’. We are designing trials that are not matching up perfectly to clinical questions.”

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