Guidelines for the treatment of rheumatoid arthritis

The 2021 guidelines published by the American College of Rheumatology (ACR) provide recommendations for deciding on the treatment interventions based on the routine clinical challenges. This update focuses on the onset and adjustment of DMARD therapy and the significance of reducing glucocorticoid use. The periodic revisions of the ACR guidelines assist in achieving the desired outcomes based on the current medical knowledge, technology, and clinical practice. However, it does not guarantee any specific outcome.

The guidelines also include updates on recommendations for methotrexate administration and its use in subjects with subcutaneous nodules, pulmonary disease, and nonalcoholic fatty liver disease (NAFLD), treatment of RA in patients with nontuberculous mycobacterial (NTM) lung disease, and use of rituximab in patients with hypogammaglobulinemia. The newer updates in the present guidelines when compared to 2015 guidelines are recommendations for patients with solid malignancies and hepatitis C.

Some of the major recommendations included in the 2021 guidelines are briefed below:

• Methotrexate is strongly recommended over hydroxychloroquine or sulfasalazine for DMARD-naïve patients with moderate-to-high disease activity.

• Initiation of a conventional synthetic DMARD (csDMARD) without short-term (<3 months) glucocorticoids is conditionally recommended over the initiation of a csDMARD with short-term glucocorticoids for DMARD-naïve patients with moderate-to-high disease activity.

• Switching to subcutaneous methotrexate is conditionally recommended over the addition of/switching to alternative DMARD(s) for patients taking oral methotrexate who are not at target.

• A split dose of oral methotrexate over 24 hours or weekly subcutaneous injections, and/or an increased dose of folic/folinic acid, is conditionally recommended over switching to alternative DMARD(s) for patients not tolerating oral weekly methotrexate.

• A treat-to-target approach is conditionally recommended over usual care for patients who have had an inadequate response to biological DMARDs (bDMARDs) or targeted synthetic DMARDs (tsDMARDs).

• Gradual discontinuation of sulfasalazine is conditionally recommended over gradual
discontinuation of hydroxychloroquine for patients taking triple therapy who wish to
discontinue a DMARD.

• Prophylactic antiviral therapy is strongly recommended over frequent monitoring of
viral load and liver enzymes alone for patients initiating rituximab who are hepatitis B core antibody-positive (regardless of hepatitis B surface antigen status).

• Methotrexate is conditionally recommended over alternative DMARDs for DMARD-naive patients with NAFLD, normal liver enzymes and liver function tests, and no evidence of advanced liver fibrosis who have moderate-to-high disease activity.

• In the setting of persistent hypogammaglobulinemia without infection, a continuation of rituximab therapy for patients at target is conditionally recommended over switching to a different bDMARD or tsDMARD.

The guidelines also highlight the need for individual treatment decisions through a shared
decision-making process based on patients’ preferences, values, goals, and comorbidities.