The American College of Rheumatology (ACR) has released the 2012 recommendations update for the use of disease-modifying antirheumatic drugs (DMARDs) and other biologic agents in the treatment of rheumatoid arthritis (RA).

The updated guidelines published in the Arthritis Care & Research (an ACR journal), are an update to the 2008 recommendations and address the issues of initiating and switching drugs, screening for tuberculosis (TB) reactivation, immunizations, and the use of biologics in high-risk RA patients.

Salient Features of the New Guidelines:

Chronological Use of Drugs

  • For patients with early Rheumatoid Arthritis (disease duration less than 6 months), the panel recommended the use of DMARD monotherapy for low disease activity and for moderate to severe disease without poor prognostic factors.
  • For patients with early RA with high disease activity and poor prognostic features, the panel recommended the use of an anti-TNF biologic with or without methotrexate.
  • For patients with established RA, treatment should be initiated or switched to a DMARD or a biologic agent regardless of prognostic features.
  • DMARD combination therapy was recommended for moderate or high disease activity with poor prognostic features in patients with early RA.
Continuation of Drugs
  • After 3 months of DMARD monotherapy, patients with deterioration of moderate or high disease activity should have methotrexate, hydroxychloroquine, or leflunomide added.
  • If a patient still has high disease activity with methotrexate or a methotrexate/DMARD combination, then a DMARD without methotrexate or a different DMARD without methotrexate should be used.
  • If there is moderate to high disease activity after 3 months of methotrexate monotherapy or DMARD combination therapy, then the patient should be switched to an anti-TNF biologic (abatacept or rituximab).
  • If the disease activity is high after 3 months of DMARD combinations or a second DMARD, then a switch to an anti-TNF biologic should be considered.
  • A switch to another anti-TNF agent or a non-TNF biologic is recommended after persistent high disease activity or loss of benefit after 3 months or because of adverse effects.
  • The panel recommended that etanercept be used in patients with hepatitis C.
  • The panel recommended against the use of biologic agents in patients with chronic hepatitis B with Child-Pugh class B or higher disease.
  • The panel did not make recommendations for patients with a history of hepatitis B or those with a positive hepatitis B core antibody.
Recommendations for Co-morbid Patients
  • Patients treated for solid tumors or nonmelanoma skin cancer more than 5 years ago may resume RA treatment with DMARDs or biologic agents if indicated for the RA itself.
  • Patients with New York class III or IV heart failure or an ejection fraction of less than 50% should not receive an anti-TNF agent.
  • Patients with a positive result on initial or subsequent tuberculin skin tests or interferon-y-release assays should have a chest radiograph and sputum examination for TB if active TB is suspected.
  • Appropriate antitubercular treatment or referral to a specialist is recommended for active or latent TB.
  • Annual TB testing is recommended in patients with RA who live, travel, or work where TB exposure is likely.
New Vaccinations
  • Vaccination is recommended for all killed (eg, pneumococcal, influenza, and hepatitis B), recombinant (human papillomavirus), and live attenuated (herpes zoster) vaccines before a course of DMARDs or a biologic agent is started.
  • In patients already receiving DMARDs or biologic agents, vaccination with killed (pneumococcal, influenza intramuscular, and hepatitis B), herpes zoster, and human papillomavirus recombinant vaccines are recommended.

Full citation: “2012 Update of the 2008 American College of Rheumatology Recommendations for the Use of Disease-Modifying Antirheumatic Drugs and Biologic Agents in the Treatment of Rheumatoid Arthritis.” Jasvinder A. Singh, Daniel E. Furst, Aseem Bharat, Jeffrey R. Curtis, Arthur F. Kavanaugh, Joel M. Kremer, Larry W. Moreland, James O’Dell, Kevin L. Winthrop, Timothy Beukelman, S. Louis Bridges Jr., W. Winn Chatham, Harold E. Paulus, Maria Suarez-Almazor, Claire Bombardier, Maxime Dougados, Dinesh Khanna, Charles M. King, Amye L. Leong, Eric L. Matteson, John T. Schousboe, Eileen Moynihan, Karen S. Kolba, Archana Jain, Elizabeth R. Volkmann, Harsh Agrawal, Sangmee Bae, Amy S. Mudano, Nivedita M. Patkar, and Kenneth G. Saag.Arthritis Care & Research; Published Online: April 2, 2012 (DOI: 10.1002/acr.21641).

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