| The American College of Rheumatology (ACR) is the | | | | to high levels of disease activity was suggested.o |
| national organization that represents much of the | | | | Recommended the prescription of anti-TNF agents |
| current thinking when it comes to arthritis care. One | | | | such as etanercept (Enbrel), infliximab (Remicade), or |
| of their major commitments has been to develop | | | | adalimumab (Humira) along with methotrexate in early |
| guidelines for treatment of various types of arthritis. | | | | RA (less than 3 months) only for patients with high |
| These guidelines are meant to instruct and perhaps | | | | disease activity who had never received DMARDs. In |
| give people an indication of what is considered | | | | intermediate- and longer-duration RA, anti-TNF agents |
| "standard of care". | | | | were recommended for patients who had failed to |
| They are not set in concrete nor are they meant to | | | | respond adequately to methotrexate therapy.o |
| restrict other therapies. Guidelines for the treatment | | | | Reserving the use of second line biologic therapies |
| of rheumatoid arthritis (RA) were last made by the | | | | such as abatacept (Orencia) and rituximab (Rituxan) |
| ACR in 2002... before the general use of biologic | | | | for patients with at least moderate disease activity |
| therapy. | | | | and poor disease prognosis for whom methotrexate |
| Rheumatoid arthritis is a chronic, systemic, | | | | in combination with or sequential administration of |
| autoimmune disorder for which there is no known | | | | other non-biologic DMARDs did not lead to an |
| cure. It affects roughly 2 million Americans. | | | | adequate response.o Avoiding the initiation or |
| Up until the turn of this past century, | | | | resumption of treatment with methotrexate, |
| disease-modifying anti-rheumatic drugs (DMARDS) | | | | leflunomide, or biologic agents for patients with active |
| were the mainstay of treatment. Because of the | | | | bacterial infection, active herpes-zoster viral infection, |
| advent of newer more effective biologic therapies, | | | | active or latent tuberculosis, or acute or chronic |
| the ACR felt it was time for a major re-evaluation of | | | | hepatitis B or C.o Not prescribing anti-TNF agents to |
| the use of DMARD therapy in rheumatoid arthritis. | | | | patients with a history of heart failure, with a history |
| They issued a set of guidelines that were recently | | | | of lymphoma, or with multiple sclerosis or |
| published. (Saag KG, et al. Arthritis Care and Research | | | | demyelinating disorders.o Avoiding the initiation or |
| 2008; 59: 762-784). | | | | resumption of methotrexate, leflunomide, or |
| These recommendations on the use of non-biologic | | | | minocycline for RA patients planning for pregnancy |
| and biologic DMARDs in RA have recently been | | | | and throughout the duration of pregnancy and |
| published and focus on 5 key areas: indications for | | | | breastfeeding. |
| use, monitoring for side-effects, assessing the clinical | | | | The authors continued on, "These recommendations |
| response, screening for tuberculosis (a risk factor | | | | are extensive but not comprehensive... and it is |
| associated with biologic DMARDs), and under certain | | | | intended that they will be regularly updated to reflect |
| circumstances (i.e. high disease activity) the roles of | | | | the rapidly growing scientific evidence in this area |
| cost and patient preference in choosing biologic | | | | along with changing practice patterns in |
| agents. When formulating these recommendations, | | | | rheumatology." |
| RA disease duration, disease severity, and prognostic | | | | Personally, I feel the guidelines are too little too late. |
| features were also considered. | | | | While I agree with the main body of their |
| The authors of these guidelines stated that, | | | | recommendations for the most part, I do disagree |
| "Applying these recommendations to clinical practice | | | | with some of their thoughts. For instance, I have |
| requires individualized patient assessment and clinical | | | | disagreement with the use of triple therapy since I |
| decision-making. The recommendations developed are | | | | don't think it works and is potentially more toxic than |
| not intended to be used in a 'cookbook' or | | | | the use of biologic therapies. In addition, the use of |
| prescriptive manner or to limit a physician's clinical | | | | second-line drugs like Orencia and Rituxan should be |
| judgment, but rather to provide guidance based on | | | | given to patients who fail the combination of a |
| clinical evidence and expert panel input." | | | | TNF-inhibitor and methotrexate. |
| The ACR 2008 recommendations include:o Initiation | | | | Newer biologic agents such as Actemra and Cimzia |
| of methotrexate or leflunomide (Arava) therapy was | | | | which are currently awaiting FDA approval will also |
| recommended for most RA patients.o Methotrexate | | | | alter the way rheumatologists approach treatment. |
| plus hydroxychloroquine (Plaquenil) was also endorsed | | | | Progress in the field of rheumatoid arthritis research |
| for patients with moderate to high disease activity.o | | | | has been astounding. With the advent of newer |
| The triple DMARD combination of methotrexate plus | | | | techniques designed to diagnose and customize |
| hydroxychloroquine plus sulfasalazine (Azulfidine) for | | | | therapies, the possibility of a cure is not too far |
| patients with poor prognostic features and moderate | | | | down the road. |