2018 update of the APLAR recommendations for treatment of rheumatoid arthritis

Abstract

AimTo update recommendations based on current best evidence concerning the treatment of rheumatoid arthritis (RA), focusing particularly on the role of targeted therapies, to inform clinicians on new developments that will impact their current practice.Materials and methodsA search of relevant literature from 2014 to 2016 concerning targeted therapies in RA was conducted. The RA Update Working Group evaluated the evidence and proposed updated recommendations using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach, to describe the quality of evidence and strength of recommendations. Recommendations were finalized through consensus using the Delphi technique.ResultsThis update provides 16 RA treatment recommendations based on current best evidence and expert clinical opinion. Recommendations 1‐3 deal with the use of conventional synthetic disease‐modifying antirheumatic drugs. The next three recommendations (4‐6) cover the need for screening and management of infections and comorbid conditions prior to starting targeted therapy, while the following seven recommendations focus on use of these agents. We address choice of targeted therapy, switch, tapering and discontinuation. The last three recommendations elaborate on targeted therapy for RA in special situations such as pregnancy, cancer, and major surgery.ConclusionRheumatoid arthritis remains a significant health problem in the Asia‐Pacific region. Patients with RA can benefit from the availability of effective targeted therapies, and these updated recommendations provide clinicians with guidance on their use.

The Future of Biosimilars: Maximizing Benefits Across Immune-Mediated Inflammatory Diseases

“…In recent years, RA treatment guidelines have proliferated, given the increasing cost of management in the biologic era. Current guidelines recommend access to biologics based on disease duration, disease severity, and number of insufficient responses to conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) [69][70][71][72][73][74][75][76], although differences in expert opinion may lead to divergent interpretations of the same evidence between guidelines. In addition, high costs and poor affordability often restrict patient access to biologics [77][78][79][80][81], alongside factors such as prescription controls and limitations in access to healthcare services [81].…”

Management of rheumatoid arthritis: 2019 updated consensus recommendations from the Hong Kong Society of Rheumatology

“…In line with our 2011 recommendations for first-line DMARD treatment of RA [5], the general consensus is still that patients should receive MTX monotherapy [10,12,45]. Despite the increasing evidence of the b/tsDMARDs in RA [59, 60, 62-68, 70, 72, 182], there remains insufficient evidence to support a recommendation for b/tsDMARDs as first-line therapy.…”

“…Although we do not provide specific statements on the risk of infection during b/tsDMARD therapy, any ongoing GC bridging therapy should be discontinued before starting a b/tsDMARD. It is prudent to protect against the most common vaccine-preventable infections in patients with RA, including Pneumococcus, influenza, HBV, human papilloma virus, and herpes zoster [12,45]. If the first b/tsDMARD fails, patients should be switched to another b/tsDMARD with the same or a different mode of action to the initial b/tsDMARD.…”

“…Tapering of csDMARDs has also been recently investigated in patients with early RA and sustained response, who had been treated in a treat-to-target manner after initial randomization to triple csDMARD therapy or MTX monotherapy [163]. It is generally thought that csDMARD tapering should entail cautious dose reduction without complete withdrawal [10,12].…”

“…As a result of rising standards of care and the availability of more therapeutic options, RA treatment is becoming increasingly complex, and recommendations developed by professional societies are increasingly important for providing rheumatologists with evidence-based guidance on best-practice treatment approaches for their patients [9,10,12]. Updated recommendations from the European League Against Rheumatism (EULAR) and the Asian Pacific League of Associations for Rheumatology (APLAR) for the management of RA with DMARDs have recently been published [10,12]. Given the advances in RA management that have been made since our last set of recommendations were published in 2011 [9], we have now updated the Hong Kong Society of Rheumatology (HKSR) recommendations for the management of RA, with a focus on how best to integrate newly available DMARDs into Hong Kong clinical practice.…”