The American College of Rheumatology (ACR) has released the 2012
recommendations for the use of disease-modifying antirheumatic drugs
(DMARDs) and biologic agents in the treatment of rheumatoid arthritis
(RA). The guidelines published today in the ACR journal, Arthritis
Care & Research, are an update to the 2008 recommendations
and address the issues of initiating and switching drugs, screening for
tuberculosis (TB) reactivation, immunization, and the use of biologics
in high-risk RA patients.
More than one million Americans suffer with RA—a chronic disease that
causes pain, swelling and inflammation in the lining of the joints—and
75% of those affected are women according to the ACR. DMARDs such as
methotrexate and hydroxychloroquine may be used individually or in
combination with biological agents to treat RA. Biological agents
include the tumor necrosis factor (TNF) inhibitors adalimumab,
cerotlizumab pegol, etanercept, golimumab or infliximab; or the non-TNF
biological drugs, abatacept, tocilizumab or rituximab. Biologics should
not be used together.
“Effective treatment of RA is essential to control disease progression
and improve quality of life for patients,” says Dr. Jasvinder Singh with
the University of Alabama at Birmingham, the principal investigator for
the 2012 update of the ACR RA guidelines for the use of DMARDs and
biological agents. “With additional advancements in RA therapies since
2008, it was important to update recommendations that help guide
rheumatologists in treating RA patients receiving DMARDs or biologic
therapies.”
The 2012 DMARD and biologic agents recommendations included a number of
areas but concentrated on four updated sections:
-
Indications for use and switching of DMARDs and biologics
-
Use of biologic agents in high-risk RA patients with hepatitis,
cancer, or congestive heart failure
-
Screening for TB in RA patients starting or receiving biologic drugs
-
Vaccination in patients starting or receiving DMARDS or biologics
Dr. Singh further explains, “The recommendations for DMARD and biologic
treatment provide a guide for rheumatologists who care for RA patients.
However, these guidelines should not replace important physician-patient
discussions or individual clinical decisions that take into account
assessments of risk-benefits, patient preferences, and economic
considerations.”
The authors suggest that low disease activity or remission should be the
goal for each RA patient, but each patient’s therapy target should be
specific to their particular health needs. One of the noted changes from
the 2008 guidelines is more aggressive treatment in patients with early
RA that is within six months of symptom onset. Researchers believe the
recommended change to more intensive early therapy is that earlier
treatment may provide better outcomes; joint damage in RA is
irreversible, making prevention of damage an important goal; and
preserving physical function and health-related quality of life is
necessary to reduce disability.
A related editorial is also available today in Arthritis
Care & Research. Co-author Dr. David Daikh, Associate
Professor of Clinical Medicine at the University of California, San
Francisco and Chief of Rheumatology at the VA Medical Center comments,
"The treatment of RA is a rapidly changing field with new therapies
regularly becoming available. As this field evolves, the recommendations
for treatment with DMARDs and biologic drugs will need to be modified in
the future and the ACR must be nimble in keeping these guidelines as
current as possible."
