Liana Fraenkel, MD, MPH: ACR 2021 Treatment Guidelines for Rheumatoid Arthritis

Rheumatology Network interviewed Liana Fraenkel, MD, MPH to discuss the recent updates to the American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis. Fraenkel served as part of the Core Leadership Team and is a rheumatologist at Berkshire Medical Center and Director of Patient Centered Population Health Research. She explains the differences between the 2015 and 2021 guidelines, the key takeaways, and the clinical significance of these changes.

To view our coverage of the guidelines, click here.

Rheumatology Network: Why was this update so important?

Liana Fraenkel, MD, MPH: The American College of Rheumatology updates its clinical practice guidelines at the minimum of every 5 years to ensure that rheumatologists have the most up-to-date information available to them. These guidelines include specific recommendations for rheumatoid arthritis which is our most common chronic inflammatory arthritis.

Liana Fraenkel, MD, MPH

RN: What are the main differences between the 2015 and 2021 guidelines?

LF: The main differences between the 2015 and 2021 guidelines are that we now conditionally recommend against using low-dose prednisone as bridge therapy. Another difference is that we now recommend adding a biologic over adding sulfasalazine and hydroxychloroquine (which would equate to triple therapy) for patients who are not doing well enough on methotrexate.

RN: What do rheumatologists need to know about the 2021 guidelines?

LF: The main points emphasized the guidelines are to maximize the use of methotrexate before advancing to a biologic or targeted synthetic disease-modifying antirheumatic drug (DMARD). We also include recommendations for how to manage side effects associated with methotrexate in order to increase the number of patients who can remain on methotrexate monotherapy. As mentioned above, the recommendation is now to escalate the methotrexate with addition of a biologic over advancing her triple therapy. Another key take away is to try to avoid glucocorticoids whenever possible, including low-dose glucocorticoids.Treated target continues to be strongly recommended for patients with not been previously treated with biologic DMARDs or targeted synthetic DMARDs, but the recommendation is conditional for those with previous experience on these medications. Further, there are several additional recommendations for specific patient populations including patients with subcutaneous nodules and pulmonary liver disease. For the first time the guidelines also address patients with nontuberculous mycobacterial lung disease.

RN: What is the clinical significance?

LF: We hope that these guidelines help support best practices across rheumatologist in the right states. The guidelines also revealed several gaps in the literature for which further research is required to answer key clinical questions including at what dose methotrexate should be started, what are the best mechanisms to try to decrease side effects to the methotrexate, further data to compare the effectiveness and safety between DMARDs, and how best to treat patients with prevalent comorbidities.

RN: Were there any sticking points (for both the voting panel and patient panel)?

LF: There were several sticking points, ie more difficult decisions at the panel deliberated on. One was regarding the need for bridge therapy with low-dose prednisone. It is recognized that many patients will require prednisone to help manage her symptoms until DMARDs kick in. However, because of the toxicity associated with even low doses of prednisone, and the common finding that patients remain on low-dose prednisone much longer than originally planned when using as bridge therapy, the panel’s recommendation was now to recommend against the use of low-dose prednisone even as bridge therapy. This is not meant to eliminate this oxygen for patients who needed, it is meant to ensure that rheumatologists do not default to using bridge therapy but that rather this is only used when absolutely necessary. The other major sticking point was on whether patients that were not doing well enough on methotrexate should escalate to triple therapy or to adding a biologic or targeted synthetic DMARD. Again, this recommendation required significant deliberation. In the end, the patient's preference for earlier onset of treatment persuaded the panel to recommend a biologic or targeted synthetic DMARD over triple therapy. Studies also showing that it is difficult for some patients to remain on triple therapy, most probably due to sulfasalazine, was also taken into consideration. There were also 2 areas where patients and the remaining of the voting panel disagreed. One was on the initial use of combination conventional synthetic DMARDs over methotrexate monotherapy. Patient's preferred initial treatment with combination because of its incremental benefits, whereas clinicians do not feel that this incremental benefit warranted the additional burden of toxicity associated with combination therapy. This difference was also noted in 2015 guidelines. In addition, patients were also strongly for discontinuing DMARDs when tapering over dose reduction, whereas the clinicians preferred the latter.

RN: Were there any items that still need to be decided?

LF: The guidelines cited several areas where there was insufficient evidence to permit any recommendations. We actually published a table including over 10 important areas where data are needed to make important clinical decisions in everyday practice. These include issues surrounding methotrexate administration, how best to implement treat to target strategies, comparative effectiveness and safety data between her different agents, as well as how best to treat patients with important comorbidities.

RN: What are the priorities for the next guidelines?

LF: Originally these guidelines were meant to address other areas which are very important for patient care including nonpharmacologic therapy and vaccine administration. Both of these issues will be undertaken in efforts by other panels.