Guideline Updates for RA, JIA Recommend Maximizing Biologics and Reducing Steroid Use

Updates to the guidelines for the management of rheumatoid arthritis (RA) and juvenile idiopathic arthritis (JIA) were previewed at the American College of Rheumatology (ACR) annual meeting, but the full list of recommendations and evidence is still under review and has not been published.

For the RA guideline, the updates will focus on maximizing the use of methotrexate and biologics and minimizing the use of steroids. Early treatment of RA, which can stop joint pain and swelling and prevent joint damage, results in better long-term results. The updated recommendations focus solely on pharmacologic treatments, although future guidelines will include nondrug therapies and vaccines.

The guidelines were developed by a broad range of stakeholders, including rheumatologists, methodologists, and patients with RA.

They emphasize starting patients on methotrexate and maximizing the use of the treatment by continuing it instead of switching quickly to another disease-modifying antirheumatic drug (DMARD). The guidelines will also now recommend that rheumatologists add a biologic or targeted synthetic DMARD before switching patients to triple therapy, which is a change from past recommendations.

ACR is also now recommending that rheumatologists minimize the use of steroids to treat RA inflammation. This is a conditional recommendation based on the serious side effects associated with glucocorticoids.

Finally, the guidelines include recommendations on drug tapering and treatment of patient populations that were not covered in previous guidelines, such as patients with pulmonary disease, nonalcoholic fatty liver disease, and nontuberculous mycobacterial lung disease. To craft these recommendations, physicians with other specialties were invited to review and provide their input.

“Despite the many treatment recommendations included in this guideline, there are a number of remaining questions to address in more frequent, future updates. This guideline is a living document. As more therapies for RA emerge, we will modify what we recommend now,” principal investigator Liana Fraenkel, MD, MPH, professor adjunct in the Division of Rheumatology, Allergy and Immunology at Yale University School of Medicine, said in a statement.

In the JIA guidelines, the recommendations address both pharmacologic and nonpharmacologic treatments. The guidelines were created with input from a 16-member panel of patients and parents of children with JIA, as well as a core team of pediatric rheumatologists and methodologists.

The guidelines emphasize a reduced use of steroids to treat inflammation and an increased use of biologics to modify disease activity, as well as strong recommendations that most children with JIS get regular immunizations. However, immunosuppressed children should still refrain from live virus immunizations.

“Pediatric rheumatologists now more rapidly escalate disease-modifying treatment in JIA patients, and are much less likely to use oral or intravenous steroids,” Karen Onel, MD, chief of the Division of Pediatric Rheumatology at the Hospital for Special Surgery in New York City, said in a statement. “This is especially true for children with systemic JIA. In addition, and this is very timely, the evidence strongly shows that children with JIA should receive and will respond to vaccines without a risk of flare. We are strongly encouraging children to follow the immunization schedule when safe and to receive annual flu shots.”