Controversial ACR 2015 RA Treatment Guidelines

Writing guidelines is challenging. Nobody said this stuff was easy. The challenge is to try to lend support to current clinical paradigms through an established base of evidence. Unfortunately, the available base of evidence was never created to answer many of our current clinical questions.

Let’s start by looking at how guidelines are created. The initial step is to develop a set of clinically important questions/recommendations for the management of a disease process like RA. The second step is to search, compile, and score available evidence into quality levels (i.e., very low, low, moderate, and high). The final and most important step is to build consensus for the questions/recommendations based on this available evidence.

There are two obvious challenges. There often lacks clear evidence to answer the clinically important questions. Consensus building is largely based on "expert opinion" guided by available evidence. Are we really just fooling ourselves to think our guidelines are evidence-based when they are largely eminence-based?

Evidence for this comes from recommendations with low levels of supporting evidence that subsequently receive a strong recommendation from the consensus panel,"Despite the low quality of evidence the recommendation is strong …" For example, although there is only low quality evidence for DMARD monotherapy in mildly active Early Rheumatoid Arthritis (ERA), the consensus panel made a strong recommendation to use monotherapy in these patients. Although there is little evidence, it’s ok to make a strong recommendation. Really?

I'll touch on another one of the recommendations that does not fit as well with current clinical paradigms. In moderate to severe ERA patients who are naive to DMARD therapy, the guidelines report "moderate to high" levels of evidence for DMARD monotherapy over combination therapy (PICO A.4 & A.5). However, in 2015 the use of initial combination therapy is widespread among clinically practicing rheumatologists. Why? Because it works! The guidelines do state the consensus panel only "conditionally" supported this evidence. There is a high level of evidence for what many clinical rheumatologists consider "substandard care" that was "conditionally" supported by the consensus panel. Really?

Of course, these are also eminence-based opinions. Really? You can discuss amongst yourselves, but this will make for interesting conversations at your local Journal Club!

More reports from ACR 2015