Liana Fraenkel, MD, MPH, on A Preview of the ACR Guideline for the Management of Rheumatoid Arthritis

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The American College of Rheumatology (ACR) guideline for the management of rheumatoid arthritis (RA) is currently under review and will soon be published. In this video, Principal Investigator Liana Fraenkel, MD, MPH, previews the clinical recommendations for the pharmacologic treatment of RA that are included in the guideline. Dr Fraenkel had discussed the recommendations—which will serve as an update to the 2015 recommendations—during ACR Convergence.

Additional Resource:

  • Fraenkel L. Presentation of the new RA guidelines. Preview presented at: American College of Rheumatology Convergence 2020; November 5-9, 2020; Virtual. 

Liana Fraenkel, MD, MPH, is a rheumatologist at Berkshire Medical Center where she is the director of Patient Centered Population Health Research. Dr Fraenkel is also an adjunct professor at Yale School of Medicine.


Liana Fraenkel: Hi, everybody. My name is Liana Fraenkel. I am a rheumatologist here at Berkshire Medical Center. I’m also the head of Population Health Research here and an adjunct professor at Yale University.

Many of you have already heard some of the excerpts from the guidelines that were presented at ACR Convergence this year. I’d like just to summarize some of the main results.

This was a large endeavor to reupdate the guidelines that were published last in 2015. There was an extensive set of PICO questions developed to really try to come up with all the relevant clinical questions to help manage patients with rheumatoid arthritis. In the PICO questions, we covered both pharmacologic and nonpharmacologic questions, but the first set of guidelines are addressing pharmacologic options only.

The future recommendations for vaccination in a more general set of patients with inflammatory diseases will be published, and nonpharmacologic management options will also be published in a future guideline manuscript.

In terms of these guidelines, I should emphasize that, currently, they are still in draft form. They have not yet been approved or published, and so I will talk about some general findings that we had, but these, again, have not been finalized yet.

In terms of the main recommendations, the overall story is that we recommended that methotrexate continue to be used as the anchor drug for almost all of our patients. Certainly for all our patients with moderate to high disease activity, methotrexate is recommended as the initial agent. And we also emphasize the need to stick with methotrexate and to escalate it appropriately before adding or switching DMARDs. We address dosage. We address how to manage patients who have some intolerance to methotrexate and how to escalate appropriate use of methotrexate before switching. We also address how to escalate care in patients who are intolerant of or who have not reached target on methotrexate.

There is some differences between our recommendations and both those published by EULAR and in 2015. The recommendation now is conditionally for adding a biologic or targeted synthetic DMARD over triple therapy. And this not surprisingly raised a lot of questions at the ACR meeting, and the main reason for this recommendation, albeit conditional, was based on patients’ preference for a regimen that had a more rapid onset of action.

The rationale for all the recommendations will be published, as well as the underlying evidence, when the guideline is published. Hopefully in the next couple of months or so.

In addition, we cover several recommendations on how to taper, which are a little bit more detailed than in the 2015 guidelines. The recommendations do favor continuing all DMARDs actually and recommend tapering only when it is the strong preference of the patient.

In this case, the recommendation is to slowly lower the dose of a drug and not discontinue it. And in cases where patients strongly prefer to discontinue a medication, the recommendation is to slowly taper it and not to abruptly taper it because of the increased risk of flares with the latter approach. And again, the references for those recommendations will be available when the guideline is published.

In addition, we do cover several recommendations for specific higher risk populations. Some of those have been covered before, such as with congestive heart failure and hepatitis.

We did not include a recommendation for hepatitis C in this set of guidelines because of the really dramatic change in treatment for patients with hepatitis C, with most patients now being able to be cured within a few months, and so we didn’t feel the recommendations were appropriate anymore.

In addition, we did not cover recommendations for patients with malignancies given that more recent updates have found different results from those originally published. And so we felt that the story was no longer as clear to make recommendations against certain classes of medications and those have not been included in this set of guidelines.

We do make new recommendations that have not been previously covered for patients with other comorbidities or complications of rheumatoid arthritis, including nodulosis as well as lung disease and NAFLD.

In addition, we do address nontuberculous mycobacterial infections and that was based on a lot of input from clinicians during our initial stakeholder meeting to develop the PICO questions.

So again, the importance is this is to provide some guidance to give rheumatologists an update on the literature, but throughout it is obviously recognized that patients all bring individual challenges to decision‑making, and their input is required for each of these decisions.