We have systematically reviewed current RA guidelines. First, 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? Finally, what guidelines will be needed in future years? The existence of multiple guidelines raises several questions. Many guidelines for managing RA have been published over recent years many of them have been updated to take into account new treatments and novel research evidence about existing treatments.
Guidelines can help minimise unnecessary care. They provide explicit recommendations to influence practice through a formal process of disseminating advice on effective management. 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. Conclusionsįive 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. Eight recommended tapering biologics when patients achieved sustained good responses. Most did not make specific recommendations about using one class of biologics preferentially. Twenty made recommendations about biologics invariably suggesting their use after failing conventional DMARDs, particularly methotrexate.
Nineteen recommended combination DMARDs when patients failed to respond fully to monotherapy and biologics were not necessarily indicated. The 21 guidelines considering early RA all recommended starting disease modifying drugs (DMARDs) as soon as possible methotrexate was recommended for most patients. All guidelines recommend treating active RA 13 made recommendations for moderate disease. Twenty recommended targeting remission 16 suggested low disease activity as alternative. Most guidelines recommend regular assessments based on the Outcome Measures in Rheumatology core dataset 18 recommended the disease activity score for 28 joints. Three dealt with early RA, one established RA and 18 all patients. They were primarily developed by rheumatologists with variable involvement of patient and other experts. We identified 529 articles 22 met our inclusion criteria. We undertook narrative assessments due to the heterogeneity of the guidelines. We included guidelines providing recommendations on general RA management spanning a range of treatments and published in English.
We 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 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.
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