ACR Treatment of Rheumatoid Arthritis Guideline Summary

Design and created by Guideline Central in participation with the American College of Rheumatology.

Document Overview

Full Text Guideline: acrjournals.onlinelibrary.wiley.com/doi/10.1002/acr.24596

Source Citation: Fraenkel L, Bathon JM, England BR, St Clair EW, Arayssi T, Carandang K, Deane KD, Genovese M, Huston KK, Kerr G, Kremer J, Nakamura MC, Russell LA, Singh JA, Smith BJ, Sparks JA, Venkatachalam S, Weinblatt ME, Al-Gibbawi M, Baker JF, Barbour KE, Barton JL, Cappelli L, Chamseddine F, George M, Johnson SR, Kahale L, Karam BS, Khamis AM, Navarro-Millán I, Mirza R, Schwab P, Singh N, Turgunbaev M, Turner AS, Yaacoub S, Akl EA. 2021 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis. Arthritis Care Res (Hoboken). 2021 Jul;73(7):924-939. doi: 10.1002/acr.24596. Epub 2021 Jun 8. PMID: 34101387; PMCID: PMC9273041.

Document Objectives

To develop a new evidence‐based, pharmacologic treatment guideline for rheumatoid arthritis (RA).

Diseases/Conditions (MeSH)

D001172 - Arthritis, Rheumatoid

Target Provider Population: All clinicians who manage adult patients with rheumatoid arthritis (RA)

PICO Questions

At what dose and route of administration should methotrexate be started?
Does switching to non-methotrexate DMARDs improve tolerability over increasing the dose of folic acid, or using folinic acid or using split dose or subcutaneous dosing, for RA patients with side effects when taking methotrexate?
What is the efficacy of TTT in different patient populations (early versus late, bDMARD- or tsDMARD-exposed, elderly-onset, comorbidities)?
What is the optimal target and method of assessment of disease activity for TTT in different populations?
What is the comparative effectiveness/safety between bDMARDs and tsDMARDs?
What is the comparative effectiveness/safety between adding bDMARDs or tsDMARDs to methotrexate and switching to bDMARD or tsDMARD monotherapy?
What is the comparative effectiveness/safety between TTT by maximizing use of methotrexate (i.e., escalating dose via subcutaneous route) and adding/switching to bDMARD or tsDMARD monotherapy?
When, which, and how should DMARDs be tapered/discontinued?
Do clinical or biologic markers predict a differential response to DMARDs?
What is the effectiveness/safety of alternative treatment strategies in RA patients with clinical lung disease or NAFLD?
Which DMARDs can be initiated or continued after receiving checkpoint inhibitor therapy?
Which DMARDs should be used in patients with solid malignancies, including skin cancer?
Is there a time frame before which DMARDs can be started/resumed in patients with concomitant solid malignancies?