ACR's New Guidelines on RA: What's New for You

In my first report about the 2014 ACR Annual Meeting, I wondered whether we were due for a revolution in rheumatology. You might have thought a revolution was actually underway, if you were part of the throngs that surged toward the Ballroom doors yesterday, to hear about the new rheumatoid arthritis guidelines.

In fact, if revolution can be equated to surprising advances, then the Boston conference is indeed bringing the revolution I foresaw.

The ACR Updated Recommendations for the Management of Rheumatoid Arthritis were my biggest surprise at the meeting. They were presented as a “draft,” anticipating publication in 2015.

There was a recommendation provided in 2008 and then in 2012, so I would have expected another 4 years before any additional information was provided. This is earlier than anticipated. Perhaps this suggests an acceleration in the progress of our understanding of rheumatoid arthritis and its management.  

•    Vaccines:  There was a re-emphasis on the use of vaccination in the draft guidelines presented yesterday. In my experience, this is important to revisit, since it seems that rheumatologists are not universally pursuing vaccination for the immunomodulated patient.  

•   Biologics:    Established RA patients who are DMARD failures are recommended to progress to combination DMARDs or TNF inhibitors (TNFi), with or without methotrexate or non-TNFi biologic agents, with or without methotrexate or tofacitinib - thus leveling this playing field that was initially reserved for TNFi.  The major changes came in the stratification of the biologics and biologic response modifiers, particularly the role of non-TNF biologic agents and tofacitinib in the management of RA with comorbidities.  

•    Hepatitis C:  In 2012, treatment of hepatitis C was limited to the use of etanercept in 2012.  However, in 2014, DMARDs, TNF inhibitors (TNFi), non-TNF biologics or tofacitinib are now listed as recommended.

•    Hepatitis B:  Untreated or treated hepatitis B had no recommended treatment in 2012; biologic agents were included as "not recommended."  By contrast, in 2014, patients with active hepatitis B infections and receiving effective anti-viral treatment could be treated with DMARDs, TNFi, non-TNF biologic or tofacitinib as recommended interventions. 

•    Solid Tumor Malignancies:  In 2012, use of biologics in the setting of solid malignancy was categorized as greater than 5 years after treatment with biologic agents, but was confined to rituximab with malignancy less than 5 years, treated melanoma or treated lymphoproliferative malignancies.  In 2014, the 5-year limitation has been lifted, and the following changes were made:  

- non-melanoma skin cancer & RA treated with DMARDs or non-TNF biologics over TNFi

- melanoma skin cancer & RA treated with TNFi over tofacitinib

- previously treated lymphoproliferative disorders with DMARDS or a non-TNF biologic over TNFi

- patients with previously treated solid organ malignancy are now recommended to be treated the same as patients without this condition.

Congestive heart failure (CHF):  In the 2012 guideline, there are no recommendations for the management of NYHA Class III/IV CHF in RA patients , but anti-TNF agents are deemed to be "not recommended."  In 2014, combination DMARDS or non-biologic therapy or tofacitinib are recommended over TNFi, but TNFi are no longer listed as "not recommended."

Serious infection:  In the 2012 guideline, the issue of serious infection is not addressed. However, in 2014, combination DMARD is recommended over TNFi, and abatacept over TNFi but TNFi are not listed as “not recommended.”  Further, there is a lack of consensus on the role of either rituximab or tocilzumab over TNFi.  Interestingly enough, no comment is directed towards tofacitinib.