Managing RA 2015 – A Preview

With myriad new therapies for rheumatoid arthritis (RA) and emerging results on the effectiveness of treat-to-target (T2T), the management of RA must evolve. The American College of Rheumatology’s (ACR) 2015 draft recommendations for managing RA, issued yesterday at the annual ACR meeting in Boston, include not only use of new agents but also tried-and-true therapies within the context of treat-to-target (T2T).

For the first time, ACR’s recommendations include guidance on glucocorticoid (GC) use and an expanded list of new biologics as well as the JAK inhibitor tofacitinib (Xeljanz), along with therapy tapering strategies, and safety considerations for infections like hepatitis, risks for congestive heart failure (CHF), and guidance on vaccinations.

The panel also considered costs in clinical practice, says Jasvinder A. Singh MD MPH, an associate professor of medicine at the University of Alabama Birmingham, who led the guidelines committee. However there was no cost-benefit analysis, he adds.

The ACR now strongly recommends using T2T rather than a non-targeted treatment strategy, in both early and established RA. While the targets continue to be low disease activity and remission, the clinician and the patient can choose another target.

“Guidelines are designed to be advisory and not prescriptive, to help improve care for RA patients and decrease healthcare costs” but built on a solid base of evidence, Singh stresses.

Among other 2015 ACR recommendations:

•  ACR affirmed that methotrexate (MTX) should be the first-line therapy for all RA patients, but initial monotherapy can also include leflunomide, sulfasalazine and hydrochloroquine.

•  Corticosteroids should be used at “the lowest possible dose for the shortest possible time” to provide the best risk-benefit ratio for the patient.

•  If a patient is doing well and RA is under control, switching from one therapy to another should only be done at the discretion of the treating physician in consultation with the patient. It should not be done arbitrarily. (ACR advises that all patients with RA should see a rheumatologist).

•  Functional status assessment (using a standardized, validated tool) should be done routinely for RA patients at least once a year, but more often in active RA.

•  Patients with a previously treated or untreated non-melanoma skin cancer should have combination DMARD therapy with a non-tumor necrosis factor alpha α (TNFα) drug rather than a TNF inhibitor (TNFi). For those with treated or untreated melanoma skin cancer, TNF inhibitors should be used in preference to drugs with other modes of action, e.g. tofacitinib.

•   For patients with a previously treated lymphoproliferative disorder, a combination DMARD or a non-TNF biologic (e.g., abatacept, tofacitinib, or rituximab) is preferable to a TNFi.

•  Those with active hepatitis B or hepatitis C infections receiving effective anti-viral treatment can be treated with either with DMARDs, TNFi’s, non-biologic TNF drugs, or tofacitinib.

•  Patients with established RA and CHF- and such patients getting worse on current TNF treatment -- can be treated with DMARDs, non-TNF biologics, or tofacitinib rather than TNFis.

The draft guidelines will be reviewed by ACR members and its respective journals before they are finalized and released in the spring of 2015, says Singh.