Living guidelines for inflammatory arthritis: Australian recommendations start with DMARD management   

Thursday, 22 Apr 2021

Prof Sam Whittle

Australian rheumatologists can now look to living guidelines for localised, evidence-based recommendations on pharmacological management of inflammatory arthritis.

The guidelines, developed by an expert panel chaired by Professor Rachelle Buchbinder of ANZMUSC, currently cover DMARD dose reduction and discontinuation strategies for rheumatoid arthritis, axial spondyloarthritis and psoriatic arthritis in adult patients, and are expected to grow over time.

“We have two main aims in creating Australian rheumatology guidelines,” said co-author Professor Sam Whittle, a rheumatologist at The Queen Elizabeth Hospital, Adelaide.

“The first is to create recommendations that are specifically tailored to the Australian context so that they will be of the highest relevance for Australian guideline users,” he told the limbic.

“Secondly, our guidelines are currently unique in the rheumatology world in that they are ‘living’ guidelines, in which individual recommendations are updated in near real-time as new evidence is produced.”

He noted that with ‘non-living’ guidelines such as those produced by EULAR, about half of the practice recommendations are changed in subsequent updates.

Submitted for NHMRC approval, the guidelines are expected to help rheumatologists navigate the rapidly evolving treatment landscape and Australia’s complex regulations around novel drugs, such as biologic or targeted synthetic DMARDs, according to the clinical guidelines register.

Rheumatologists appear enthusiastic about localised guidelines, with around 80% of surveyed ARA members considering them “necessary” for clinical practice. Presently, 87% use rheumatology guidelines, with 46% relying on European rheumatology associations’ guidelines and 36%, American.

Among the top priorities for rheumatologists — and the guidelines – are DMARD dose reduction and discontinuation in patients with low disease activity or remission, selection in people who have failed to respond to csDMARDs or b/ts DMARDs and use in the perioperative period and pregnancy.

“We have already covered some of these topics and anticipate recommendations on many more on this list [of 34 topics highlighted in a two-stage survey of ARA members] in the next few months,” said Prof Whittle.

“Our most recent recommendation is the use of COVID-19 vaccines in people with autoimmune inflammatory rheumatic diseases on immunomodulatory therapies.”

As of 15 April 2021, the guidelines “conditionally” favour COVID-19 vaccination in people with AIRD on immunomodulatory drugs, however, with limited efficacy and safety data in that population, rheumatologists and patients should consider benefits, risks, current disease activity and treatment, disease management goals and individual preferences and values before deciding on a vaccine.

“We are very keen to see the recommendations widely implemented in practice,” he said.

Rheumatologists can freely access and provide feedback on the guidelines, along with research evidence, decision rationales, practical information and decision aids via the host platform MAGICapp.

In addition, rheumatologists can expect to see initial recommendations for managing juvenile idiopathic arthritis by the end of the year.

Given ANZMUSC and the ARA’s involvement in guideline development, along with support from the Targeted Therapies Alliance, Professor Whittle expected the guidelines would be “the definitive Australian rheumatology guidelines”.

“We hope that they will become they key resource for Australian rheumatologists, rheumatology consumers, and other healthcare professionals involved in the care of Australians with rheumatic diseases,” he said.

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