American College Of Rheumatology Guidelines Research Articles

Comparative performance analysis of large language models: ChatGPT-3.5, ChatGPT-4 and Google Gemini in glucocorticoid-induced osteoporosis

BackgroundsThe use of large language models (LLMs) in medicine can help physicians improve the quality and effectiveness of health care by increasing the efficiency of medical information management, patient care, medical research, and clinical decision-making.MethodsWe collected 34 frequently asked questions about glucocorticoid-induced osteoporosis (GIOP), covering topics related to the disease’s clinical manifestations, pathogenesis, diagnosis, treatment, prevention, and risk factors. We also generated 25 questions based on the 2022 American College of Rheumatology Guideline for the Prevention and Treatment of Glucocorticoid-Induced Osteoporosis (2022 ACR-GIOP Guideline). Each question was posed to the LLM (ChatGPT-3.5, ChatGPT-4, and Google Gemini), and three senior orthopedic surgeons independently rated the responses generated by the LLMs. Three senior orthopedic surgeons independently rated the answers based on responses ranging between 1 and 4 points. A total score (TS) > 9 indicated ‘good’ responses, 6 ≤ TS ≤ 9 indicated ‘moderate’ responses, and TS < 6 indicated ‘poor’ responses.ResultsIn response to the general questions related to GIOP and the 2022 ACR-GIOP Guidelines, Google Gemini provided more concise answers than the other LLMs. In terms of pathogenesis, ChatGPT-4 had significantly higher total scores (TSs) than ChatGPT-3.5. The TSs for answering questions related to the 2022 ACR-GIOP Guideline by ChatGPT-4 were significantly higher than those for Google Gemini. ChatGPT-3.5 and ChatGPT-4 had significantly higher self-corrected TSs than pre-corrected TSs, while Google Gemini self-corrected for responses that were not significantly different than before.ConclusionsOur study showed that Google Gemini provides more concise and intuitive responses than ChatGPT-3.5 and ChatGPT-4. ChatGPT-4 performed significantly better than ChatGPT3.5 and Google Gemini in terms of answering general questions about GIOP and the 2022 ACR-GIOP Guidelines. ChatGPT3.5 and ChatGPT-4 self-corrected better than Google Gemini.

Imaging in vasculitis.

Systemic vasculitides are characterized by inflammation of blood vessels. Their classification is based on the size of the blood vessels involved - large, medium, or small. Vasculitis early diagnosis and reliable monitoring are crucial to establish a treatment plan and prevent serious complications. Based on these considerations and depending on the location of the affected vessels, the importance of imaging modalities including ultrasonography (US), magnetic resonance Imaging (MRI), magnetic resonance angiography (MRA), computed tomography (CT), computed tomography angiography (CTA), and [18F]-fluoro-2-deoxy-d-glucose positron emission tomography/computed tomography (FDG-PET/CT) has progressively increased. In addition to physical exam and laboratory data, these imaging tools offer complementary information about vascular changes occurring in vasculitis.This review summarizes the different imaging modalities being utilized to diagnose and monitor vasculitis. The most recent update for the use of imaging in vasculitis is referenced in the 2023 European Alliance of Associations for Rheumatology (EULAR) recommendations and the American College of Rheumatology (ACR) guidelines in 2021. Recent advances in PET imaging in large vessel vasculitis include improved technological imaging acquisition and the use of novel radiotracers for cellular and immune targets. FDG-PET has now been demonstrated to have high sensitivity and specificity to detect temporal arteritis. Imaging plays a significant role in the evaluation of vasculitis and continues to gain importance in the diagnosis and monitoring of disease activity. Differences exist between the ACR guidelines, which advocates for temporal artery biopsy, and the EULAR guidelines, which favors imaging modalities for the initial evaluation and diagnosis of large vessel vasculitis (LVV). Prerequisites for appropriate clinical management utilizing imaging in patients with vasculitis are the availability and access to skilled clinicians to interpret the images and the cost of these techniques not being prohibitive.

Serum Sirt6 as a Potential Biomarker for Osteoarthritis and its Correlation with IL-6 Alterations.

The study aimed to assess Sirt6 levels in serum of knee osteoarthritis (OA) patients compared to healthy individuals to evaluate its correlation with OA and to understand how Sirt6 is linked with the change in IL-6 levels. The cross-sectional study involved 50 knee OA patients clinically diagnosed as per the American College of Rheumatology guidelines and 50 healthy controls. Radiological examination as per Kellgren-Lawrence (KL) criteria was done to determine the disease severity. Peripheral blood samples were collected from each participant, and serum Sirt6 and IL-6 levels were measured using ELISA. The serum Sirt6 levels in knee OA patients were significantly lower as compared to healthy controls (p = 0.023). Patients with knee OA of KL grade 4 had significantly lower Sirt6 levels as compared to those with KL grade 2 OA (p = 0.031). Individuals of younger age group had higher Sirt6 levels compared to older age group. IL-6 levels in knee OA patients were significantly higher as compared to controls (p = 0.007). A negative correlation was observed between serum Sirt6 and IL-6 levels (r = -0.407; p = 0.035). The study concludes that serum Sirt6 levels are inversely associated with knee OA and may serve as a potential biomarker for the disease. Moreover, a negative correlation between Sirt6 and IL-6 levels was observed in this study. Further investigations are necessary to confirm these findings and to explore the mechanisms by which Sirt6 and IL-6 are involved in OA.

Assessing Patient Values and Preferences to Inform the 2023 American College of Rheumatology/American College of Chest Physicians Interstitial Lung Disease Guidelines.

Patient engagement is critical to clinical practice guideline (CPG) development. This work presents our approach to ascertaining patients' values and preferences to inform the American College of Rheumatology guidelines for screening, monitoring, and treatment of interstitial lung disease (ILD) in people with systemic autoimmune rheumatic diseases (SARDs). We conducted a cross-sectional qualitative study of a purposefully sampled Patient Panel using a modified content analytic approach. The study team reviewed text transcripts from the Patient Panel discussion to identify themes and develop a clustered thematic schema. Twenty-one patients (75% women) participated, with a mean age of 53 years (range 33-73). Patients had one or more SARDs: systemic sclerosis (38%), Sjögren disease (38%), idiopathic inflammatory myopathy (33%), rheumatoid arthritis (24%), and mixed connective tissue disease (10%). We identified 10 themes in 4 thematic clusters: communication, screening and monitoring, treatment goals, and treatment adverse effects. Patients prioritized recognizing ILD symptoms, importance of ILD screening and close monitoring, goals of survival and improving quality of life, and willingness to accept treatment risks provided that there is close communication with providers. Patient representatives shared patients' priorities and insight at the Voting Panel meeting, influencing multiple guideline recommendations. Patient engagement fosters a holistic approach to CPG development, leading to recommendations aiming for the best clinical outcomes while prioritizing outcomes important for patients. The patient-identified themes played a critical role in ILD guideline development and provide core elements for shared decision-making as clinicians make management and therapeutic decisions with patients with SARD-associated ILD.

Fitwalking: A New Frontier for Kidney Patients – A Center’s Experience

Introduction: Physical inactivity is common in patients with chronic kidney disease (CKD) and is an important modifiable risk factor for mortality, morbidity, and reduced quality of life. The present single-centre pilot study evaluated the possibility of performing structured physical exercise using a specific walking model, Fitwalking, in a population of patients with CKD and, according to the American College of Rheumatology guidelines, also in a population with immuno-rheumatological disease. Methods: Patients were recruited from nephrology, haemodialysis, peritoneal dialysis, transplantation, and immuno-rheumatology outpatient clinics. After general and functional clinical evaluation and exercise prescription at the Department of Sports Medicine, we performed scientifically proven tests on CKD (6-min walk test and sit-to-stand test), before and after the Fitwalking technique training course, and again after 6 and 12 months, evaluated its effectiveness and identify any critical issues. Results: We enrolled 80 patients (41 males, 51.2%), with a mean age of 53 ± 12 years; the clinical data showed statistically significant improvements in systolic, average, and differential blood pressure, average speed, and physical strength. Participants also adapted to muscle fatigue, experienced a reduction in BMI with stable lean mass and reduced fat mass, and reported improved perceptions of physical and mental health, and quality of life. Conclusion: All enrolled patients successfully completed the process. A specific prescription was used that provided health education and allowed for the implementation of structured physical activity that could be performed safely and independently even after the training period. The activity was sustainable thanks to the training of in-house medical and nursing staff, demonstrating that it is possible to overcome this type of barrier to physical activity in CKD and in immuno-rheumatological patients.

Knowledge of and Stated Adherence to the 2020 ACR Guideline for Gout Management: Results of a Survey of US Rheumatologists.

This report evaluates rheumatologists' stated adherence to and agreement with the 2020 American College of Rheumatology (ACR) Guideline for the Management of Gout. A 57-item questionnaire was administered to a sample of US rheumatologists. Stated adherence scores were based on several guideline recommendations reported to be followed by rheumatologists in practice, whereas stated agreement scores were based on whether respondents always followed the recommendations. All 201 rheumatologists approached completed the questionnaire. The mean overall stated adherence score was 11.5 (maximum 15), whereas the mean overall stated agreement score was 7.7 (maximum 14). Less experienced rheumatologists (≤ 8 yrs; n = 49) were likely to claim adherence to more individual ACR recommendations than those with more experience (> 8 yrs; n = 152; mean stated adherence score: 12.3 vs 11.3; P ≤ 0.05). Rheumatologists who claimed to see ≤ 75 patients with gout in 6 months (n = 66) had a mean stated adherence score of 12.1 vs 11.2 for those who claimed to have seen > 75 patients (P ≤ 0.05). Approximately 78% of rheumatologists claimed to follow the guideline for initiating urate-lowering therapy (ULT), and 89% were likely to prescribe allopurinol as a first-line ULT. Claimed adherence to recommendations for dosing was lower (febuxostat: 43%; allopurinol: 39%). Rheumatologists from academic settings were more likely to prescribe an interleukin-1 inhibitor for gout flares. The self-reported practice of the surveyed US rheumatologists was generally concordant with the 2020 ACR Guideline for the Management of Gout. However, there were gaps in guideline knowledge and stated adherence among rheumatologists, mainly concerning the dosing of treatment regimens.

Effect of Steroids on Patients With Fibromyalgia/Chromic Widespread Pain: An Observational Study.

Fibromyalgia causes widespread chronic pain. Pain management and treating underlying conditions are of utmost importance. Recent studies found an association of thyroid autoimmunity with fibromyalgia. Pain management of patients with anti-thyroid peroxidase antibody (anti-TPO Ab) positive was studied sparsely. To determine the effect of steroid (deflazacort) on pain management using numerical rating scale (NRS) pain score at baseline and at 3-month follow-up. A retrospective observational study was undertaken, recruiting patients diagnosed with fibromyalgia as per 2010 American College of Rheumatology guidelines and treated with the steroid, deflazacort 12 mg. Patients with missing details were excluded. Patients were categorized into negative, positive, and strongly positive anti-TPO Ab groups. Baseline and follow-up (3 months) pain score was compared across the groups. Reduction in pain was considered as a primary outcome variable. The study included 128 participants with 98 (76.6%) females and 30 (23.4%) males. The age of the study population was 48±13.29 years. The proportion of hyper, hypo, and euthyroidwas 10 (7.81%), 42 (32.81%), and 76 (59.38%), respectively. The proportion of participants with negative, positive, and strongly positive anti-TPO Ab levels was 41 (32.03)%, 50 (39.06%), and 37 (28.91%), respectively.Baseline pain score was 7.3±1.32 and 3-month follow-up was 4.7±2.46. Steroid response was found in 66 (51.6%). Negative andpositive anti-TPO Ab had a 1-point reduction in pain score from baseline, p-value <0.001. The strongly positive group had 5 points reduction, p-value<0.05. Fibromyalgia patients with thyroid autoimmunity responded well to short courses of steroids. Greater pain relief was observed among those who are strongly positive anti-TPO Ab group.

Glucocorticoid-Induced Osteoporosis: Increased Awareness as a Management Strategy for Prevention of this Complication in Patients with Systemic Autoimmune Rheumatic Disease.

It has been estimated that about 1% of the US population is treated with long-term glucocorticoids. High doses of glucocorticoids particularly those used by rheumatologists and oth- ers for systemic autoimmune rheumatic disease result in bone loss, causing glucocorticoid-induced osteoporosis and an increase in the risk of fractures. The increased risk is related to both the daily dose and the cumulative dose of the glucocorticoids. Despite the availability of effective preventative and treatment options, glucocorticoid-induced osteoporosis is often not mitigated with the use of these preventive therapies. The risk of glucocorticoid-induced osteoporosis often also goes under- recognized, because it occurs in a different group of patients compared to age-related osteoporosis. As a result, glucocorticoid-induced osteoporosis is not always treated until after fractures may have occurred. Our objective is to determine if a structured health-care provider's educational interven- tion with intermittent educational updates would lead to improvement in the identification, evalu- ation, and prevention of glucocorticoid-induced osteoporosisin those patients at the highest risk of glucocorticoid-induced osteoporosis. In this single-center, prospective study, patients over 40 years of age, receiving a total cumu- lative dose of glucocorticoids of >5 g or a single dose of >30 mg of prednisone or its equivalent was enrolled. All providers attended an academic Journal Club, where the current American College of Rheumatology guidelines regarding glucocorticoid-induced osteoporosiswas reviewed. All providers received monthly reminders during academic meetings within the department. There was a statistically significant improvement between pre- and post-educational data, with increasing use of glucocorticoid-induced osteoporosis preventive measures, which was sus- tained over the 12-month duration of the study. This research shows the importance of provider education as a means of disseminating information and improving the quality of patient care.

PartII: Interactive case:Drug‐inducedendocrine disorders

Part<scp>II</scp>: Interactive case:<scp>Drug‐induced</scp>endocrine disorders

Vaccination for rheumatic diseases: Current issues (based on ACR guidelines)

In modern rheumatology, comorbid infections have a significant impact on morbidity and mortality, especially in immuno-inflammatory rheumatic diseases (IIRD). One of the ways to solve this problem is the study and active use of various vaccines. This article analyzes the recommendations for vaccination of patients with acute respiratory infections, proposed in 2022 by experts of the American College of Rheumatology (ACR). The safety and immunogenicity of vaccination associated with the prevention of various infections in patients with IVR are discussed. It is emphasized that the decision to suspend taking the drug before or after vaccination should be made taking into account the existing IIRD, its activity and the risk of vaccine-controlled infection. A key component of any vaccination strategy (especially for conditional recommendations) is decision-making together with the patient. The main directions of future research on the problem under consideration are outlined.

Real-world treatment of gout and asymptomatic hyperuricaemia in Japan.

Recently a retrospective cohort study in Japan conducted by Koto et al. disclosed that the risk of the first gout flare would decrease 55% if serum uric acid was reduced to 5–6 mg/dl among people with asymptomatic hyperuricaemia receiving uric acid–lowering drugs as compared with untreated people (serum uric acid ≥ 8.0 mg/dl) [1]. Another study by Koto et al. published in Modern Rheumatology using the same database disclosed that the prevalence of gout was about 1.1% in Japan [2], which was lower than Taiwan (3.1%) [3].The authors commented that the low prevalence of gout in Japan could be attributed to the early drug treatment of asymptomatic hyperuricaemia based on the Japanese guideline [2, 4]. Both studies by Koto et al. provide the evidence that the natural course of asymptomatic hyperuricaemia can be changed by the intervention of uric acid–lowering drugs. Some points are discussed. First, hyperuricaemia and gout are closely related but are not the same disease. Most of the people with hyperuricaemia do not develop a gout flare during their lives [5]. Whether people with asymptomatic hyperuricaemia should take uric acid–lowering drugs to prevent the first gout flare, the academic community has not yet established a consensus. The American College of Rheumatology guideline suggests against the use of uric acid–lowering drugs to treat asymptomatic hyperuricaemia [6]. The Japanese guideline suggests that the treatment goal of hyperuricaemia is to prevent monosodium urate deposition in joints and viscera, not only leading to the risk reduction of gout flares but also leading to the risk reduction of organ damage and then leading to prolonged disease-free survival, especially cardiovascular diseases [4]. After lifestyle modification, if serum uric acid is still ≥ 9.0 mg/dl, clinicians may talk to people with asymptomatic hyperuricaemia about the current evidence of managing hyperuricaemia and possible adverse events of uric acid–lowering drugs, such as hepatotoxicity, urinary stones, and cutaneous adverse reactions. Only after informed consent is obtained, clinicians are able to consider prescribing uric acid–lowering drugs to those suitable patients [4]. Although serum uric acid ≥ 9.0 mg/dl is an independent risk factor for gout flares, there have been no randomized control studies focusing on the management of asymptomatic hyperuricaemia where the primary endpoint was set as the development of the first gout flare. Therefore, in the current situation, urate-lowering drugs are not strongly recommended for asymptomatic hyperuricaemia in order to prevent the first gout flare. Moreover, in the present guidelines, how to treat hyperuricaemia should be decided after assessing the patients’ concomitant diseases. Second, benzbromarone is a uricosuric drug to lower serum uric acid. Because of its potential hepatotoxicity, benzbromarone had been withdrawn from some markets since 2003, but it still can be prescribed in many countries including Taiwan and Japan [7]. Three case reports in Japan showed that benzbromarone could be related to fulminant hepatotoxicity, but none was confirmed by rechallenge tests [8–10]. However, no hepatotoxicity was reported in Taiwan and South Korea. Allopurinol is the first drug of choice to lower serum uric acid in western countries [6]. Allopurinol use has a potential risk to cause severe cutaneous adverse reactions. Among the three Asian countries, the incidence rate of allopurinol-related severe cutaneous adverse reactions was the highest in Taiwan (2.57/1000 person-years), followed by South Korea (2.31/1000 person-years), and the lowest in Japan (2.00/1000 person-years) [11]. In ethnic groups with a high frequency of HLA-B*5801, benzbromarone will be safer than allopurinol for the management of hyperuricaemia. The standard doses of benzbromarone (100 mg/day) are more effective in lowering serum uric acid than the standard doses of allopurinol (300 mg/day) [12]. Only higher doses of allopurinol (450 mg/day) are as equally effective in lowering serum uric acid as the standard doses of benzbromarone (100 mg/day) [12]. Third, current guidelines do not present which drug should be the first-line drug for asymptomatic hyperuricaemia. If we want to set up a new clinical guideline, it is necessary to determine which drug is more effective and safer to prevent the first gout flare in people with asymptomatic hyperuricaemia. It indicates a future research direction.

Trends in Total Joint Arthroplasty Among Patients With Rheumatoid Arthritis: The Effect of Recent Disease Modifying Antirheumatic Drug Utilization Guidelines.

The 2015 change in the American College of Rheumatology (ACR) guidelines narrowed indications for initiating treatment with biologic disease-modifying antirheumatic drugs (bDMARDs) in patients with rheumatoid arthritis (RA). This study sought to evaluate trends in total joint arthroplasty (TJA) in patients with RA and to characterize the effect of bDMARDs on arthroplasty risk in this population after the change in ACR treatment guidelines. A retrospective review was conducted using the PearlDiver database. TJA procedures included total shoulder arthroplasty, total elbow arthroplasty, total hip arthroplasty, and total knee arthroplasty. The Cochran-Armitage Trend Test was used to evaluate trends in the volume of TJA procedures conducted in patients with RA between 2010 and 2019. Logistic regression was used to compare 2-year arthroplasty risk after an initial joint-specific RA International Classification of Diseases 10th Revision diagnosis for RA patients with versus without bDMARD exposure. A total of 2,942,360 patients with RA were identified, and 80,744 (2.74%) underwent TJA between 2010 and 2019. Rates of TJA procedures trended significantly upward over the decade (2.6% versus 5.1%, P < 0.001) with a sharp increase between 2015 and 2016 (2.1% versus 4.9%, P < 0.001). Among the 16,736 identified patients with an initial International Classification of Diseases 10th Revision joint-specific RA diagnosis, 3362 patients (20.09%) were treated with bDMARDs and 13,374 (79.91%) were not. Untreated patients exhibited significantly lower risk of any TJA (5.92% versus 7.73%; odds ratio [OR]: 0.72; 95% confidence interval [CI]: 0.64 to 0.82), total hip arthroplasty (OR: 0.69, 95% CI: 0.50 to 0.95), and total knee arthroplasty (OR: 0.63, 95% CI: 0.52 to 0.75) compared with treated patients. The volume of TJA procedures conducted in patients with RA has trended markedly upward over the past decade, with a sharp increase after 2015. bDMARD treatment was associated with markedly increased risk of TJA, likely because of initiation of bDMARDs in only those patients with advanced disease per ACR guidelines.

Recommendations for the treatment of rheumatoid arthritis in Saudi Arabia: adolopment of the 2021 American College of Rheumatology guidelines

BackgroundThe 2021 American College of Rheumatology (ACR) rheumatoid arthritis (RA) guideline considers the specific context of the United States which differs from that of Saudi Arabia in many aspects that may impact recommendations. The objective of this project was to adapt a set of prioritized recommendations from the 2021 ACR guideline for the treatment of rheumatoid arthritis RA for the context of Saudi Arabia, by the Saudi Society for Rheumatology (SSR).MethodsThe process followed the GRADE-ADOLOPMENT methodology, and the reporting adhered to the RIGHT-Ad@pt checklist. Working groups included a coordination group and a 19-member panel representing different stakeholder groups. The Evidence to Decision (EtD) tables included evidence on health effects from the source guideline and contextual information from the Saudi setting.ResultsThe panel prioritized and adapted five recommendations from the source guideline. The process led to modifying two out of the five prioritized recommendations, all listed here. In naive patients with low disease activity, methotrexate (MTX) is conditionally recommended over sulfasalazine (SSZ) (modified direction); hydroxychloroquine (HCQ) is conditionally recommended over SSZ (unmodified). Initiation of csDMARDs with short-term glucocorticoids is conditionally recommended over csDMARDs alone in naive patients with moderate to high disease activity (modified direction). Switch to subcutaneous MTX is conditionally recommended over addition/switch to alternative DMARD(s) in patients taking oral MTX who are not at target (unmodified). Discontinuation of MTX is conditionally recommended over gradual discontinuation of the bDMARD or tsDMARD for patients taking MTX plus a bDMARD or tsDMARD who wish to discontinue a DMARD (unmodified).ConclusionRheumatologists practicing in Saudi Arabia can use the adoloped recommendations generated by this project while adopting the rest of the recommendations from the 2021 ACR guidelines.

Impact of specialty pharmacy collaboration with rheumatology clinics to improve the achievement of treat-to-target goals in patients with rheumatoid arthritis: a pilot study

In rheumatoid arthritis, the use of Routine Assessment of Patient Index Data 3 (RAPID3) assessments to meet treat-to-target goals is endorsed by the 2021 American College of Rheumatology guidelines. In November 2020, the Baylor Scott & White specialty pharmacy implemented a new service that included more frequent collection of RAPID3 scores and standardized provider communication for patients co-managed by a Baylor Scott & White rheumatology clinic. The objective was to evaluate the impact of this new service on rheumatoid arthritis disease activity. Before the new service started, patients followed a protocol of RAPID3 assessments that occurred every 6 months; once the service began, patients were followed using an algorithm in which patients with higher disease activity were contacted more frequently. Eighty-six percent of patients in the pre-intervention group (n = 7) compared with 100% of patients in the post-intervention group (n = 10) had high to moderate disease activity at baseline. Within a 6-month follow-up period in both groups, the percentage of high to moderate disease activity patients decreased by 30% in the post-intervention group and remained the same in the pre-intervention group. These results support the positive impact increased specialty pharmacy services may have on clinical outcomes; therefore, the continued expansion of these services should be considered.

Baricitinib in COVID-19: a coming-of-age from artificial intelligence to reducing mortality

Baricitinib in COVID-19: a coming-of-age from artificial intelligence to reducing mortality

Evaluation of Access Disparities to Biologic Disease-Modifying Antirheumatic Drugs in Rural and Urban Communities.

The American College of Rheumatology guidelines provides a strong recommendation for the use of biologic disease-modifying antirheumatic drugs (bDMARDs) when conventional rheumatoid arthritis treatments fail to meet treatment targets. Although bDMARDs are an effective and important treatment component, access inequalities remain a challenge in many communities worldwide. The purpose of this analysis is to assess nationwide trends in bDMARD access in the United States, with a specific focus on rural and urban access gaps. This study combined multiple county-level databases to assess bDMARD prescriptions from 2015 to 2019. Using geospatial analysis and the Moran’s I statistic, counties were classified according to prescription levels to assess for hotspots and coldspots. Analysis of variance (ANOVA) was used to compare significant counties across 49 socioeconomic variables of interest. The analysis identified statistically significant hotspot and coldspot prescription clusters within the United States. Coldspot (Low-Low) clusters with low access to bDMARDs are located predominantly in the rural west North Central region, extending down to Oklahoma and Arkansas. Hotspot (High-High) clusters are seen in urban and metro areas of Wisconsin, Minnesota, Pennsylvania, North Carolina, Georgia, Oregon, and the southern tip of Texas. Comparing coldspot to hotspot areas of bDMARD access revealed that the Medicare populations were older, more rural, less educated, less impoverished, and less likely to get their bDMARDs from a rheumatologist.

2021 American College of Rheumatology Guideline for the Treatment of Juvenile Idiopathic Arthritis: Recommendations for Nonpharmacologic Therapies, Medication Monitoring, Immunizations, and Imaging.

To provide recommendations for the management of juvenile idiopathic arthritis (JIA) with a focus on nonpharmacologic therapies, medication monitoring, immunizations, and imaging, irrespective of JIA phenotype. We developed clinically relevant Patient/Population, Intervention, Comparison, and Outcomes questions. After conducting a systematic literature review, the Grading of Recommendations Assessment, Development and Evaluation approach was used to rate the quality of evidence (high, moderate, low, or very low). A Voting Panel including clinicians and patients/caregivers achieved consensus on the direction (for or against) and strength (strong or conditional) of recommendations. Recommendations in this guideline include the use of physical therapy and occupational therapy interventions; a healthy, well-balanced, age-appropriate diet; specific laboratory monitoring for medications; widespread use of immunizations; and shared decision-making with patients/caregivers. Disease management for all patients with JIA is addressed with respect to nonpharmacologic therapies, medication monitoring, immunizations, and imaging. Evidence for all recommendations was graded as low or very low in quality. For that reason, more than half of the recommendations are conditional. This clinical practice guideline complements the 2019 American College of Rheumatology JIA and uveitis guidelines, which addressed polyarthritis, sacroiliitis, enthesitis, and uveitis, and a concurrent 2021 guideline on oligoarthritis, temporomandibular arthritis, and systemic JIA. It serves as a tool to support clinicians, patients, and caregivers in decision-making. The recommendations take into consideration the severity of both articular and nonarticular manifestations as well as patient quality of life. Although evidence is generally low quality and many recommendations are conditional, the inclusion of caregivers and patients in the decision-making process strengthens the relevance and applicability of the guideline. It is important to remember that these are recommendations. Clinical decisions, as always, should be made by the treating clinician and patient/caregiver.

2021 American College of Rheumatology Guideline for the Treatment of Juvenile Idiopathic Arthritis: Recommendations for Nonpharmacologic Therapies, Medication Monitoring, Immunizations, and Imaging.

To provide recommendations for the management of juvenile idiopathic arthritis (JIA) with a focus on nonpharmacologic therapies, medication monitoring, immunizations, and imaging, irrespective of JIA phenotype. We developed clinically relevant Patient/Population, Intervention, Comparison, and Outcomes questions. After conducting a systematic literature review, the Grading of Recommendations Assessment, Development and Evaluation approach was used to rate the quality of evidence (high, moderate, low, or very low). A Voting Panel including clinicians and patients/caregivers achieved consensus on the direction (for or against) and strength (strong or conditional) of recommendations. Recommendations in this guideline include the use of physical therapy and occupational therapy interventions; a healthy, well-balanced, age-appropriate diet; specific laboratory monitoring for medications; widespread use of immunizations; and shared decision-making with patients/caregivers. Disease management for all patients with JIA is addressed with respect to nonpharmacologic therapies, medication monitoring, immunizations, and imaging. Evidence for all recommendations was graded as low or very low in quality. For that reason, more than half of the recommendations are conditional. This clinical practice guideline complements the 2019 American College of Rheumatology JIA and uveitis guidelines, which addressed polyarthritis, sacroiliitis, enthesitis, and uveitis, and a concurrent 2021 guideline on oligoarthritis, temporomandibular arthritis, and systemic JIA. It serves as a tool to support clinicians, patients, and caregivers in decision-making. The recommendations take into consideration the severity of both articular and nonarticular manifestations as well as patient quality of life. Although evidence is generally low quality and many recommendations are conditional, the inclusion of caregivers and patients in the decision-making process strengthens the relevance and applicability of the guideline. It is important to remember that these are recommendations. Clinical decisions, as always, should be made by the treating clinician and patient/caregiver.

Provider Specialty and the Use of Disease‐Modifying Antirheumatic Drugs for Rheumatoid Arthritis Among Older Adults in the 2005‐2016 National Ambulatory Medical Care Survey

ObjectiveWe compared disease‐modifying antirheumatic drug (DMARD) use for older adults with rheumatoid arthritis (RA)‐related ambulatory visits from rheumatologists and primary care providers (PCPs).MethodsIn this study of national sample office visits, we characterized ambulatory visits by older adults 65 years of age or older seen by rheumatologists or PCPs for diagnosis of RA using the 2005‐2016 National Ambulatory Medical Care Survey. We analyzed patterns and trends of DMARD use using descriptive statistics and multivariable analyses by provider specialty.ResultsWe identified 518 observations representing 7,873,246 ambulatory RA visits by older adults over 12 years; 74% were with rheumatologists. Any DMARD use was recorded at 56% of rheumatologist and 30% of PCP visits. Among visits with any DMARD use, 20% of rheumatologist visits had two or more DMARDs compared with 6% of PCP visits. Over the 12‐year study period, there was no statistical difference in trend of any or conventional synthetic DMARD use at visits by provider specialty, adjusted for patient characteristics, non‐DMARD polypharmacy and multimorbidity. However, biologic DMARD use was more likely to incrementally increase with rheumatologist compared with PCP visits (P = 0.003).ConclusionDMARD use for older adults with RA remains low from both rheumatologists and PCPs, including biologic DMARDs, even though American College of Rheumatology guidelines recommend earlier and more aggressive treatment of RA. With predicted shortages in the rheumatology workforce and maldistribution of rheumatology providers, PCPs may play an increasingly important role in caring for older adults with RA. Further research is needed to understand to optimize appropriate use of DMARDs in older patients with RA.

Use of protocol-driven medication refills by pharmacists decreases rheumatologist in-basket work and improves rheumatologist satisfaction

Burn-out among US physicians has been on the rise in the past few decades. Similarly, rheumatologists in the Geisinger Health System have experienced professional dissatisfaction through significant administrative burden and...