Abstract
BackgroundWe systematically reviewed current guidelines for managing rheumatoid arthritis (RA) to evaluate their range and nature, assess variations in their recommendations and highlight divergence in their perspectives.MethodsWe searched Medline and Embase databases using the terms ‘clinical practice guidelines’ and ‘rheumatoid arthritis’ from January 2000 to January 2017 together with publications of national and international bodies. We included guidelines providing recommendations on general RA management spanning a range of treatments and published in English. We undertook narrative assessments due to the heterogeneity of the guidelines.ResultsWe identified 529 articles; 22 met our inclusion criteria. They were primarily developed by rheumatologists with variable involvement of patient and other experts. Three dealt with early RA, one established RA and 18 all patients. Most guidelines recommend regular assessments based on the Outcome Measures in Rheumatology core dataset; 18 recommended the disease activity score for 28 joints. Twenty recommended targeting remission; 16 suggested low disease activity as alternative. All guidelines recommend treating active RA; 13 made recommendations for moderate disease. The 21 guidelines considering early RA all recommended starting disease modifying drugs (DMARDs) as soon as possible; methotrexate was recommended for most patients. Nineteen recommended combination DMARDs when patients failed to respond fully to monotherapy and biologics were not necessarily indicated. Twenty made recommendations about biologics invariably suggesting their use after failing conventional DMARDs, particularly methotrexate. Most did not make specific recommendations about using one class of biologics preferentially. Eight recommended tapering biologics when patients achieved sustained good responses.ConclusionsFive general principles transcend most guidelines: DMARDs should be started as soon as possible after the diagnosis; methotrexate is the best initial treatment; disease activity should be regularly monitored; give biologics to patients with persistently active disease who have already received methotrexate; remission or low disease activity are the preferred treatment target.
Highlights
We systematically reviewed current guidelines for managing rheumatoid arthritis (RA) to evaluate their range and nature, assess variations in their recommendations and highlight divergence in their perspectives
The existence of multiple guidelines raises several questions. As they have all had access to the same research data, albeit at different time-points, are there recommendations similar or are there substantial differences between them? Second, why are there different guidelines dealing with the same issue – how best to treat RA? Thirdly, what is the impact of these guidelines on clinical practice? what guidelines will be needed in future years?
Guidelines identified We identified 529 potential guidelines articles: 80 were assessed in detail; 22 guidelines [14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35] selected because they met our inclusion criteria (Fig. 1). These included two European League Against Rheumatism (EULAR) guidelines, which provided general guidance and guidance of treat to target [22, 34], and four different guidelines from the United Kingdom [6, 7, 24, 25], which were produced by various groups at different times and worked from varying perspectives
Summary
We systematically reviewed current guidelines for managing rheumatoid arthritis (RA) to evaluate their range and nature, assess variations in their recommendations and highlight divergence in their perspectives. Guidelines for the management of rheumatoid arthritis (RA) produced by expert groups based on assessments of the research evidence have been produced for over 25 years [1,2,3,4]. They provide explicit recommendations to influence practice through a formal process of disseminating advice on effective management. The existence of multiple guidelines raises several questions As they have all had access to the same research data, albeit at different time-points, are there recommendations similar or are there substantial differences between them? As they have all had access to the same research data, albeit at different time-points, are there recommendations similar or are there substantial differences between them? Second, why are there different guidelines dealing with the same issue – how best to treat RA? Thirdly, what is the impact of these guidelines on clinical practice? what guidelines will be needed in future years?
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