Bernard Combe, MD, PhD, France

A long-awaited update to the ACR Guidelines for RA was presented at the ACR Convergence 2020 this month. Since the last update in 2015, the field has seen both new data and approved therapies.1 I know, for me personally, I take into consideration both local and international guidelines when considering strategies for managing my patients’ disease, which is why it is important to review and reflect on the updates.

Many of the core recommendations in the newest ACR guidelines remain closely aligned with the previous version and stress the importance of:1,2

  • Early evaluation, diagnosis, and management
  • Reevaluating treatment decisions approximately every 3 months
  • Using the treat-to-target strategy with frequent monitoring of disease activity using validated instruments

One update to the guidelines was the third point above, related to treat-to-target. The 2020 ACR guidelines conditionally recommend making low disease activity (LDA) the initial treatment goal in patients who have failed ≥ 1 biologic DMARD (bDMARD) or targeted synthetic DMARD (tsDMARD).

The ACR chose this approach because it recognises the challenges in achieving remission for patients who have already failed a biologic or tsDMARD. Key factors that influenced the change in the ACR guidelines targeting LDA over remission included the facts that:

  • Remission may not be achievable in some patients
  • Failure to reach the target may be disheartening to patients

This change in recommendations sits in contrast to the EULAR guidelines, which recommend the primary target for the treatment of RA to be a state of clinical remission.3,4 The EULAR guidelines opt for an evidence-based approach and refer to studies that show patients who achieve remission have better outcomes, even over those who achieve low disease activity.4 You can read more about some of these data on another blog posted on this site.

I feel both guidelines provide important perspectives and highlight how each individual patient’s goals should be considered when we make treatment decisions. I believe we should strive for remission where possible given the evidence, but also understand this may not be achievable for all patients.

At my institution and at rheumatology practices across the globe, these international guidelines always play important roles when it comes to patient management. I look forward to hearing others’ perspectives on these new recommendations as we await the final published guidelines.

Continued commentary and discussions on the ACR guidelines will be presented soon on this site in a podcast led by multiple rheumatologists from the UK. Be sure to check back for additional perspectives.

Bernard Combe, MD, PhD
Professor of Rheumatology at Montpellier University, France
Head of the Bone and Joint Department at Montpellier University Hospital

ACR, American College of Rheumatology; bDMARD, biologic disease-modifying antirheumatic drug; EULAR, European League Against Rheumatism; LDA, low disease activity; RA, rheumatoid arthritis; tsDMARD, targeted synthetic DMARD.

References: 1. Singh JA, et al. Arthritis Rheumatol. 2016;68(1):1-26. 2. Fraenkel L, et al. ACR Convergence 2020. Presentation [session 5M018]. 3. Smolen JS, et al. Ann Rheum Dis. 2020;0:1-15. 4. Smolen JS, et al. Ann Rheum Dis. 2016;75:3-15.