RheumJC Twitter Chat: Are the ACR RA Guidelines Adequate?

In selecting the most appropriate care for my patients, there are always a few factors I take into consideration.

What is the likelihood that a patient will successfully adhere to the vigorous regime of triple therapy with a multitude of daily pills, often several times a day? Will the cost of certain therapeutics unduly burden the patient? What does the patient want or prefer in regards to choices in medications? For example, sometimes there are patients who absolutely refuse biologic therapies.  [[{"type":"media","view_mode":"media_crop","fid":"49741","attributes":{"alt":"Christopher Collins, M.D.","class":"media-image media-image-right","id":"media_crop_5558894226687","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"6047","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"font-size: 13.008px; line-height: 1.538em; float: right;","title":"Christopher Collins, M.D.","typeof":"foaf:Image"}}]]

I consider myself fairly aggressive in management of rheumatoid arthritis. Many times when patients have failed one oral DMARD (typically methotrexate), I’m likely to go to a TNF or another biologic drug depending on the scenario. However, there are other cases in which I’ve felt it more appropriate prescribing combination oral therapy. And the truth is, in over 10 years of practice, guidelines really haven't changed how I approach these varied treatment decisions. Most guidelines have remained somewhat generic in their recommendations of who should go on what and when.  

One thing is certain, it’s never clear-cut. Patients are individuals who must be treated as such.

#RheumJC Twitter chat

June 30:  4-5 p.m. EST and 10-11 p.m. EST.

Instructions on participating.

For me, as a rheumatologist, treatment guidelines periodically issued by the American College of Rheumatology (ACR) or EULAR are just that, guidelines. I rely on them for guidance. Treatment decisions are ultimately individualistic and made in concert with the patient, and grounded in evidence-based medicine.

But every physician is different. Some want a more specific blue print, which is why some physicians were dissatisfied with the 2015 ACR treatment guidelines for rheumatoid arthritis.

Writing in Nature Reviews Rheumatology, Ronald van Vollenhoven , M.D., Ph.D., who is Director of the Amsterdam Rheumatology and Immunology Center and holds many other prestigious posts, stated that, “Despite its technical solidity - and perhaps partly because of it - the 2015 ACR guideline is somewhat lackluster and disconnected from the most topical issues in RA therapeutics. As a result, it has limited applicability to actual clinical care.”

This is true to a degree. Research happens at such a fast pace that guidelines can sometimes be obsolete the minute they’re published. Aspiring for definitive guidelines in this day and age is like chasing rainbows.

There will always be gaps and missed opportunities, but the guidelines are based on grounded methodologies that present learning opportunities for physicians.

What we’d like to achieve with the Twitter-based Rheumatology Journal Club (#RheumJC) is to create a dialogue with physicians nationally and internationally. During our next monthly Twitter chat (June 30), I’m interested in learning about practice patterns that are different in different parts of the world and in learning how many international communities look to ACR or EULAR or other sources to help to guide them in making treatment decisions. Or, are they mostly bound by the inherit nature of their own healthcare systems?

I’d like to discuss what part of the RA guidelines are generalizable and what is relative to an international global population. And, I would be curious to know if other physicians participating in the chat believe there should be more specificity in the RA guidelines. Or, do they feel they are adequate? What omissions should have been included in the guidelines?

I would encourage everyone who is planning to attend the online chat to read the guidelines and the opinion piece. We’re eager to learn from their own interpretation of the guidelines.

Christopher Collins, M.D., is an associate professor of medicine at Georgetown University and serves as director of the lupus clinic at MedStar Washington Hospital Center in Washgington D.C. He is co-creator of the Rheumatology Journal Club and a member of the Rheumatology Network editorial board.

References:

Jasvinder A Singh, Kenneth Saag., et al. 

"2015 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis,"

Arthritis Care & Research

, DOI 10.1002/acr.22783, 2015, American College of Rheumatology.  Ronald van Vollenhoven. 

"Rheumatoid arthritis: Missed opportunities in the 2015 ACR guideline for RA treatment," 

Nature Reviews Rheumatology 

12, 135–136 (2016) doi:10.1038/nrrheum.2015.181. Published online 14 January 2016