Rheumatoid Arthritis
Key Points
Key Points
- Focus on common clinical scenarios, not exceptional cases
- Cost is a consideration in these recommendations. However, explicit cost-effectiveness analyses were not conducted.
- Disease activity measurement using an ACR-recommended measure should be performed in a majority of encounters with patients with rheumatoid arthritis (RA1).
- Functional status assessment using a standardized, validated measure should be performed routinely for RA patients, at least once per year, but more frequently if disease is active. Examples of commonly used functional status measures include Health Assessment Questionnaire (HAQ), Health Assessment Questionnaire-II (HAQ-II), Multidimensional Health Assessment Questionnaire (MD-HAQ), Patient-Reported Outcomes Measurement Information System , Physical Function 10-item, PROMIS Physical Function 20-item, and PROMIS Physical Function Computerized Adaptive Tests (PROPFCAT).
- If a patient has low RA disease activity or is in clinical remission, switching from one therapy to another should be considered only at the discretion of the treating physician in consultation with the patient.
Arbitrary switching between RA therapies based only on a payer/insurance company policy is not recommended. - A treatment recommendation favoring one medication over another means that the preferred medication would be the recommended first option. However, favoring one medication over the other does not imply that the non-favored medication is contraindicated for use in that situation; it may still be a potential option under certain conditions.
Table 1. Definitions
Key Terms and Definitions
- Adult RA patient
- Adults, 18 years and older, meeting the ACRRA2, 3 classification criteria.
- Health Benefits and Harms
- Efficacy and safety of treatments including desirable and undesirable effects.
- Early RA
- RA with duration of disease/symptoms of <6 months, where “duration” denotes the length of time the patient has had symptoms/disease, not the length of time since RA diagnosis.
- Established RA
- RA with duration of disease/symptoms of ≥6 months OR meeting 1987 ACRRAa classification criteria.
- Disease activity
- Categorized as low, moderate, or high as per validated scales
(Table 3). Moderate and high disease activity categories were combined, as used previously for the 2012 ACRRA1 treatment recommendations.
- RA remission
- A joint ACR-EULAR task force defined remission as a tender joint count, swollen joint count, C-reactive protein (mg/dL) and patient global assessment ≤1 each or a Simplified Disease Activity Score (DAS4) of ≤ 3.3, one of 6 ACR-endorsed disease activity measures.b
- Optimal dosing of RA treatments
-
- Dosing to achieve a therapeutic target derived from mutual patient-clinician consideration of patient priorities, and
- Given for ≥3 months before therapy escalation or switching.
- DMARD failure
- Failure of traditional/conventional DMARD(s) due to lack of efficacy/desired response or side effects.
- Biologic failure
- Failure of biologic(s) due to lack of efficacy/desired response or side effects.
- Secondary biologic failure
- A biologic was efficacious initially but subsequently became inefficacious.
- Active hepatitis B infection
- Hepatitis B surface antigen positive, Hepatitis B surface antibody negative, Hepatitis B core antibody total positive (less important), AST/ALT typically increased, HBV DNA positive (if checked).
- Hepatitis C infection
- HCV antibody positive, HCV RNA positive, AST/ALT typically increased.
- NYHA class III and IV
-
- NYHA class III includes patients with cardiac disease resulting in marked limitation of physical activity with less than ordinary physical activity causing fatigue, palpitation, dyspnea, or angina, but no symptoms at rest.
- NYHA5 class IV includes patients with cardiac disease resulting in inability to carry on any physical activity without discomfort, symptoms of heart failure are present even at rest, and discomfort increases if any physical activity is undertaken.
b Any of the ACR-recommended disease activity measures may be chosen, as described in Anderson et al.1
Table 2. Agents Used in Treating RA
...ble 2. Agents Used in Treating RAHaving trouble...
Assessment
...ssessme...
...ble 3. Instruments to Measure Rheumatoid...
Treatment
...eatment
...ommendations for Patients with Symptoma...
...of disease activity level, use a treat-to-target...
...onotherapy (MTX preferred) over double t...
...se DMARD monotherapy (MTX preferred)...
...therapy over double therapy. (Conditional,...
use DMARD monotherapy over triple therapy...
...disease activity remains moderate or hig...
...a TNFi monotherapy over tofacitini...
use a TNFiMTX over tofacitinib MTX. (Conditional,...
...onditional, Moderate)578...
...herapies, (Conditional, Low)578
...ares, add short-term glucocorticoids a...
.... Early Rheumatoid Arthritis...
...5. Recommendations for Patients with Establ...
...disease activity level, use a treat-to-ta...
...e activity is low, in patients who have never tak...
...erapy (MTX preferred) over tofacitin...
...ARD monotherapy (MTX preferred) over...
...f disease activity remains moderate or high...
...disease activity remains moderate or high despite...
...ologic, with or without methotrexate, over...
...iologic, with or without methotrexate, over tof...
...ease activity remains moderate or high despite us...
...isease activity remains moderate or...
...he disease activity still remains moder...
...another non-TNF biologic, with or without me...
...vity remains moderate or high, use tofacit...
...ase activity remains moderate or high despite...
...ease flares in patients on DMARD, TNFi, o...
...MARD therapy. (Conditional, Low)Low...
..., non-TNF biologic, or tofacitinib (...
...DMARD therapy. (Strong, Modera...
...tinue TNFi, non-TNF biologic or tofaci...
...patient’s disease is in remissio...
...of established aRA is based on the 1987 AC...
...2. Established Rheumatoid Arthr...
...ratory Monitoring for RA Patients on DMARDs...
...ble 7. Recommendations for High-Risk P...
...ve heart failure (CHF)a
...ation DMARDs or non-TNF biologic or...
... worsening on current TNFi therapyUse combinat...
Hepatitis...
...ctive Hepatitis B infection and receiving/...
...titis Cc
...nfection and receiving/received effec...
...ction and not receiving or requiring effective ant...
...y of treated or untreated malignancye...
...ated or untreated skin cancer (non-melan...
...ed lymphoproliferative disorderUse ritux...
...eviously treated lymphoproliferative disord...
...reated solid organ malignancySame recommendations...
...s Serious Infection(s)f...
...us infection(s)Use combination DMAR...
...tional recommendations supported by evidenc...
Screening/Preventive Therapy
...creening/Preventive...
...e 8. Use of Vaccines in Patients with Rheu...
...ulosis (TB) Screening Algorithm for...
References
References Anderson J, Caplan L, Yazda...