Missed opportunities in ACR RA treatment guidelines

Wednesday, 3 Feb 2016

American College of Rheumatology rheumatoid arthritis guidelines released last November are lacklustre and disconnected from the most topical issues in therapeutics, according to a recent critique.

Professor Ronald van Vollenhoven, from the Amsterdam Rheumatology and Immunology Center, said the “big picture” provided by the guideline does not look right.

“Most recommendations are bland,” he said. “In their quest for methodological rigour and purism, the authors seem to have gone too far.”

For example, when a patient with established RA fails to respond to methotrexate and has highly active disease, the guideline suggests combination DMARDs, or a TNF inhibitor, or a non-TNF biologic agent, or tofacitinib, all with or without methotrexate, in no particular order of preference.

“In other words, ‘just do something, no matter what’,” Professor von Vollenhoven said.

“The clinician would like to know what specifically is recommended, what he or she is supposed to look for, and what to consider before making a treatment decision.”

Writing in Nature Reviews Rheumatology, he said that the majority of ACR recommendations are classed as ‘conditional’ despite the wealth of current literature on RA treatment.

Even for ‘strong’ recommendations, the guideline often comments that the quality of evidence is low.

“So let’s get this straight,” Professor van Vollenhoven said.

“Over the past three decades no area in rheumatology therapeutics has been studied in as much detail as the treatment of RA, with numerous randomised controlled clinical trials – done at enormous expense – involving many of the best and brightest clinicians and academicians in our field.

“Despite all these efforts, the cumulative evidence provided by dozens of trials in thousands of patients is judged, by the ACR task force, as being unable to support but a handful of bland recommendations. This is an almost intolerable paradox.

“I suspect that an excessive reliance on formal methodology, rather than the quality of the trials themselves, is the problem.”

Practical questions that need to be addressed in future guidelines include:

  • combination therapies or biologic agents as first-line treatment
  • induction-maintenance strategies
  • comparison of the relative strengths and weaknesses of novel therapies
  • dosing considerations for biologic agents
  • use of biomarkers and imaging to guide therapy.

“A set of more practical, common-sense, reasonable and forward-looking recommendations is eagerly awaited,” he concluded.

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