2021 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis

doi:10.1002/acr.24596

Practice Guideline

. 2021 Jul;73(7):924-939.

doi: 10.1002/acr.24596. Epub 2021 Jun 8.

2021 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis

Liana Fraenkel¹, Joan M Bathon², Bryant R England³, E William St Clair⁴, Thurayya Arayssi⁵, Kristine Carandang⁶, Kevin D Deane⁷, Mark Genovese⁸, Kent Kwas Huston⁹, Gail Kerr¹⁰, Joel Kremer¹¹, Mary C Nakamura¹², Linda A Russell¹³, Jasvinder A Singh¹⁴, Benjamin J Smith¹⁵, Jeffrey A Sparks¹⁶, Shilpa Venkatachalam¹⁷, Michael E Weinblatt¹⁶, Mounir Al-Gibbawi¹⁸, Joshua F Baker¹⁹, Kamil E Barbour²⁰, Jennifer L Barton²¹, Laura Cappelli²², Fatimah Chamseddine¹⁸, Michael George²³, Sindhu R Johnson²⁴, Lara Kahale¹⁸, Basil S Karam¹⁸, Assem M Khamis¹⁸, Iris Navarro-Millán²⁵, Reza Mirza²⁶, Pascale Schwab²¹, Namrata Singh²⁷, Marat Turgunbaev²⁸, Amy S Turner²⁸, Sally Yaacoub¹⁸, Elie A Akl¹⁸

Affiliations

¹ Berkshire Medical Center, Pittsfield, Massachusetts, and Yale University School of Medicine, New Haven, Connecticut.
² Columbia University Irving Medical Center, New York Presbyterian Hospital, New York, New York.
³ University of Nebraska Medical Center and VA Nebraska-Western Iowa Health Care System, Omaha, Nebraska.
⁴ Duke University Medical Center, Durham, North Carolina.
⁵ Weill Cornell Medicine-Qatar, Doha, Qatar.
⁶ University of California, San Diego.
⁷ University of Colorado, Aurora.
⁸ Stanford University Medical Center, Palo Alto, California.
⁹ The Center for Rheumatic Disease/Allergy and Immunology, Kansas City, Missouri.
¹⁰ Veterans Affairs Medical Center, Georgetown and Howard University, Washington, DC.
¹¹ Albany Medical College and The Center for Rheumatology, Albany, New York.
¹² University of California, San Francisco.
¹³ Hospital for Special Surgery, New York, New York.
¹⁴ University of Alabama at Birmingham and Birmingham Veterans Affairs Medical Center, Birmingham, Alabama.
¹⁵ Florida State University College of Medicine School of Physician Assistant Practice, Tallahassee.
¹⁶ Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts.
¹⁷ Global Healthy Living Foundation, Upper Nyack, New York.
¹⁸ American University of Beirut, Beirut, Lebanon.
¹⁹ Corporal Michael J. Crescenz VA Medical Center and the University of Pennsylvania, Philadelphia, Pennsylvania.
²⁰ Centers for Disease Control and Prevention, Atlanta, Georgia.
²¹ Oregon Health & Science University and VA Portland Health Care System, Portland, Oregon.
²² Johns Hopkins Medicine, Baltimore, Maryland.
²³ University of Pennsylvania, Philadelphia.
²⁴ Toronto Western Hospital, Mount Sinai Hospital, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.
²⁵ Weill Cornell Medicine, New York, New York.
²⁶ University of Toronto, Toronto, Ontario, Canada.
²⁷ University of Washington, Seattle.
²⁸ American College of Rheumatology, Atlanta, Georgia.

PMID: 34101387
PMCID: PMC9273041
DOI: 10.1002/acr.24596

Practice Guideline

2021 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis

Liana Fraenkel et al. Arthritis Care Res (Hoboken). 2021 Jul.

. 2021 Jul;73(7):924-939.

doi: 10.1002/acr.24596. Epub 2021 Jun 8.

Authors

Affiliations

¹ Berkshire Medical Center, Pittsfield, Massachusetts, and Yale University School of Medicine, New Haven, Connecticut.
² Columbia University Irving Medical Center, New York Presbyterian Hospital, New York, New York.
³ University of Nebraska Medical Center and VA Nebraska-Western Iowa Health Care System, Omaha, Nebraska.
⁴ Duke University Medical Center, Durham, North Carolina.
⁵ Weill Cornell Medicine-Qatar, Doha, Qatar.
⁶ University of California, San Diego.
⁷ University of Colorado, Aurora.
⁸ Stanford University Medical Center, Palo Alto, California.
⁹ The Center for Rheumatic Disease/Allergy and Immunology, Kansas City, Missouri.
¹⁰ Veterans Affairs Medical Center, Georgetown and Howard University, Washington, DC.
¹¹ Albany Medical College and The Center for Rheumatology, Albany, New York.
¹² University of California, San Francisco.
¹³ Hospital for Special Surgery, New York, New York.
¹⁴ University of Alabama at Birmingham and Birmingham Veterans Affairs Medical Center, Birmingham, Alabama.
¹⁵ Florida State University College of Medicine School of Physician Assistant Practice, Tallahassee.
¹⁶ Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts.
¹⁷ Global Healthy Living Foundation, Upper Nyack, New York.
¹⁸ American University of Beirut, Beirut, Lebanon.
¹⁹ Corporal Michael J. Crescenz VA Medical Center and the University of Pennsylvania, Philadelphia, Pennsylvania.
²⁰ Centers for Disease Control and Prevention, Atlanta, Georgia.
²¹ Oregon Health & Science University and VA Portland Health Care System, Portland, Oregon.
²² Johns Hopkins Medicine, Baltimore, Maryland.
²³ University of Pennsylvania, Philadelphia.
²⁴ Toronto Western Hospital, Mount Sinai Hospital, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.
²⁵ Weill Cornell Medicine, New York, New York.
²⁶ University of Toronto, Toronto, Ontario, Canada.
²⁷ University of Washington, Seattle.
²⁸ American College of Rheumatology, Atlanta, Georgia.

PMID: 34101387
PMCID: PMC9273041
DOI: 10.1002/acr.24596

Abstract

Objective: To develop updated guidelines for the pharmacologic management of rheumatoid arthritis.

Methods: We developed clinically relevant population, intervention, comparator, and outcomes (PICO) questions. After conducting a systematic literature review, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to rate the certainty of evidence. A voting panel comprising clinicians and patients achieved consensus on the direction (for or against) and strength (strong or conditional) of recommendations.

Results: The guideline addresses treatment with disease-modifying antirheumatic drugs (DMARDs), including conventional synthetic DMARDs, biologic DMARDs, and targeted synthetic DMARDs, use of glucocorticoids, and use of DMARDs in certain high-risk populations (i.e., those with liver disease, heart failure, lymphoproliferative disorders, previous serious infections, and nontuberculous mycobacterial lung disease). The guideline includes 44 recommendations (7 strong and 37 conditional).

Conclusion: This clinical practice guideline is intended to serve as a tool to support clinician and patient decision-making. Recommendations are not prescriptive, and individual treatment decisions should be made through a shared decision-making process based on patients' values, goals, preferences, and comorbidities.

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Comment in

Management of Rheumatoid Arthritis: Update From ACR.
Arnold MJ. Arnold MJ. Am Fam Physician. 2022 Sep;106(3):340-342. Am Fam Physician. 2022. PMID: 36125998 No abstract available.

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References

1. Singh JA, Saag KG, Bridges SL Jr, Akl EA, Bannuru RR, Sullivan MC, et al. 2015 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Rheumatol 2016;68:1–26. - PubMed
1. Saag KG, Teng GG, Patkar NM, Anuntiyo J, Finney C, Curtis JR, et al. American College of Rheumatology 2008 recommendations for the use of nonbiologic and biologic disease-modifying antirheumatic drugs in rheumatoid arthritis. Arthritis Rheum 2008;59:762–84. - PubMed
1. Singh JA, Furst DE, Bharat A, Curtis JR, Kavanaugh AF, Kremer JM, et al. 2012 update of the 2008 American College of Rheumatology recommendations for the use of disease-modifying antirheumatic drugs and biologic agents in the treatment of rheumatoid arthritis. Arthritis Care Res (Hoboken) 2012;64:625–39. - PMC - PubMed
1. Goodman SM, Springer B, Guyatt G, Abdel MP, Dasa V, George M, et al. 2017 American College of Rheumatology/American Association of Hip and Knee Surgeons guideline for the perioperative management of antirheumatic medication in patients with rheumatic diseases undergoing elective total hip or total knee arthroplasty. Arthritis Rheumatol 2017;69:1538–51. - PubMed
1. Sammaritano LR, Bermas BL, Chakravarty EE, Chambers C, Clowse ME, Lockshin MD, et al. 2020 American College of Rheumatology guideline for the management of reproductive health in rheumatic and musculoskeletal diseases. Arthritis Care Res (Hoboken) 2020; 72:461–88. - PubMed

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[1] Singh JA, Saag KG, Bridges SL Jr, Akl EA, Bannuru RR, Sullivan MC, et al. 2015 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Rheumatol 2016;68:1–26. - PubMed

[2] Singh JA, Saag KG, Bridges SL Jr, Akl EA, Bannuru RR, Sullivan MC, et al. 2015 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Rheumatol 2016;68:1–26. - PubMed

[3] Saag KG, Teng GG, Patkar NM, Anuntiyo J, Finney C, Curtis JR, et al. American College of Rheumatology 2008 recommendations for the use of nonbiologic and biologic disease-modifying antirheumatic drugs in rheumatoid arthritis. Arthritis Rheum 2008;59:762–84. - PubMed

[4] Saag KG, Teng GG, Patkar NM, Anuntiyo J, Finney C, Curtis JR, et al. American College of Rheumatology 2008 recommendations for the use of nonbiologic and biologic disease-modifying antirheumatic drugs in rheumatoid arthritis. Arthritis Rheum 2008;59:762–84. - PubMed

[5] Singh JA, Furst DE, Bharat A, Curtis JR, Kavanaugh AF, Kremer JM, et al. 2012 update of the 2008 American College of Rheumatology recommendations for the use of disease-modifying antirheumatic drugs and biologic agents in the treatment of rheumatoid arthritis. Arthritis Care Res (Hoboken) 2012;64:625–39. - PMC - PubMed

[6] Singh JA, Furst DE, Bharat A, Curtis JR, Kavanaugh AF, Kremer JM, et al. 2012 update of the 2008 American College of Rheumatology recommendations for the use of disease-modifying antirheumatic drugs and biologic agents in the treatment of rheumatoid arthritis. Arthritis Care Res (Hoboken) 2012;64:625–39. - PMC - PubMed

[7] Goodman SM, Springer B, Guyatt G, Abdel MP, Dasa V, George M, et al. 2017 American College of Rheumatology/American Association of Hip and Knee Surgeons guideline for the perioperative management of antirheumatic medication in patients with rheumatic diseases undergoing elective total hip or total knee arthroplasty. Arthritis Rheumatol 2017;69:1538–51. - PubMed

[8] Goodman SM, Springer B, Guyatt G, Abdel MP, Dasa V, George M, et al. 2017 American College of Rheumatology/American Association of Hip and Knee Surgeons guideline for the perioperative management of antirheumatic medication in patients with rheumatic diseases undergoing elective total hip or total knee arthroplasty. Arthritis Rheumatol 2017;69:1538–51. - PubMed

[9] Sammaritano LR, Bermas BL, Chakravarty EE, Chambers C, Clowse ME, Lockshin MD, et al. 2020 American College of Rheumatology guideline for the management of reproductive health in rheumatic and musculoskeletal diseases. Arthritis Care Res (Hoboken) 2020; 72:461–88. - PubMed

[10] Sammaritano LR, Bermas BL, Chakravarty EE, Chambers C, Clowse ME, Lockshin MD, et al. 2020 American College of Rheumatology guideline for the management of reproductive health in rheumatic and musculoskeletal diseases. Arthritis Care Res (Hoboken) 2020; 72:461–88. - PubMed

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2021 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis

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2021 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis

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