The draft 2015 ACR guidelines for RA deliver some of the same old recommendations rheumatologists are already familiar with. They are still recommending DMARD monotherapy, generally MTX but other agents such as hydroxychloroquine, sulfasalazine or leflunomide can also be used as a first step. If ACR-approved targets are not reached, then move on to combination therapy or an anti-TNF agent. Medications should be optimally dosed for 3 months before switching or adding therapy.
Missing from the 2015 guidelines was any mention of bad prognostic markers or the role of triple therapy.
So what’s new in the 2015 guidelines? Mainly, recommendations for patients with comorbidities and a revisiting of vaccination before initiating biologic therapies.
Starting with malignancy, the new guidelines recommend that patients with previous non-melanoma skin cancer should preferentially receive DMARDs over anti-TNF agents, whereas anti-TNF agents are appropriate for patients with previous melanoma. Treatment strategies are the same for patients with a history of solid tumours as for those without. DMARDs or non-TNF inhibitor biologics are preferred for patients with previous lymphoproliferative disorders.
RA patients with active hepatitis B or C who are receiving antiviral therapy can receive any RA treatment. Patients with established RA and comorbid NYHA Class III or IV congestive heart failure can receive DMARDs or non-TNF inhibitor biologics or tofacitinib. Patients with a previous serious infection should preferentially be treated with combination DMARDs or abatacept over anti-TNF agents.
Finally, vaccination against herpes zoster should be done BEFORE initiating biologics. Patients already receiving biologics should NOT receive the herpes zoster vaccine.
This session was delivered in an overcrowded room, with only 10 minutes to get the overflow to an alternate location at a super-fast pace.
Dr. Boulos Haraoui is an Associate Professor of Medicine at the Université de Montréal and head of the Clinical Research Unit. His research interests focus on the diagnosis and management of rheumatoid arthritis.View Full Bio