Implementation of recommendations in rheumatic and musculoskeletal diseases: considerations for development and uptake

ObjectivesTo update the Assessment of SpondyloArthritis international Society (ASAS)-EULAR recommendations for the management of axial spondyloarthritis (axSpA).MethodsFollowing the EULAR Standardised Operating Procedures, two systematic literature reviews were conducted on non-pharmacological and pharmacological treatment of axSpA. In a task force meeting, the evidence was presented, discussed, and overarching principles and recommendations were updated, followed by voting.ResultsFive overarching principles and 15 recommendations with a focus on personalised medicine were agreed: eight remained unchanged from the previous recommendations; three with minor edits on nomenclature; two with relevant updates (#9, 12); two newly formulated (#10, 11). The first five recommendations focus on treatment target and monitoring, non-pharmacological management and non-steroidal anti-inflammatory drugs (NSAIDs) as first-choice pharmacological treatment. Recommendations 6–8 deal with analgesics and discourage long-term glucocorticoids and conventional synthetic disease-modifying antirheumatic drugs (DMARDs) for pure axial involvement. Recommendation 9 describes the indication of biological DMARDs (bDMARDs, that is, tumour necrosis factor inhibitors (TNFi), interleukin-17 inhibitors (IL-17i)) and targeted synthetic DMARDs (tsDMARDs, ie, Janus kinase inhibitors) for patients who have Ankylosing Spondylitis Disease Activity Score ≥2.1 and failed ≥2 NSAIDs and also have either elevated C reactive protein, MRI inflammation of sacroiliac joints or radiographic sacroiliitis. Current practice is to start a TNFi or IL-17i. Recommendation 10 addresses extramusculoskeletal manifestations with TNF monoclonal antibodies preferred for recurrent uveitis or inflammatory bowel disease, and IL-17i for significant psoriasis. Treatment failure should prompt re-evaluation of the diagnosis and consideration of the presence of comorbidities (#11). If active axSpA is confirmed, switching to another b/tsDMARD is recommended (#12). Tapering, rather than immediate discontinuation of a bDMARD, can be considered in patients in sustained remission (#13). The last recommendations (#14, 15) deal with surgery and spinal fractures.ConclusionsThe 2022 ASAS-EULAR recommendations provide up-to-date guidance on the management of patients with axSpA.

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“…Implementation is a crucial aspect in the process of recommendations and that is often neglected. 156…”

Section: Discussionmentioning

confidence: 99%

“…Implementation is a crucial aspect in the process of recommendations and that is often neglected 156. A dissemination strategy is currently underway which we hope will enhance the uptake and implementation of these recommendations.…”

Section: Discussionmentioning

confidence: 99%

ASAS-EULAR recommendations for the management of axial spondyloarthritis: 2022 update

et al. 2022

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“…Both these case scenarios have nurses as key managers of the care services, as is expected to be in MTX. Nevertheless, publishing recommendations does not always lead to care for improvements in practice, depending on several factors and barriers (Bennett et al., 2022), which should be considered when defining their implementation (Loza et al., 2022).…”

Section: Discussionmentioning

confidence: 99%

Towards a consensus for nurse education of methotrexate for people with rheumatic and musculoskeletal diseases: A scoping review

Marques,

Matos,

Nikiphorou

et al. 2023

Musculoskeletal Care

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IntroductionPatient education (PE) is a key role of nurses, which includes providing information, training, and support about methotrexate (MTX), an anchor drug in rheumatology. However, there is a wide variation in the access to rheumatology nurse consultations in Europe, and there is a lack of consensus regarding the delivery, context and timing of PE in these cases. This study aimed to provide a comprehensive overview of the existing research on nurse education of MTX for children/youth and adults with Rheumatic and Musculoskeletal Diseases (RMDs).MethodsThis scoping review was conducted in accordance with Arksey and O’Malley's framework. A search on PubMed (MEDLINE), Scopus and Cochrane Database, and CINAHL, from inception until March 2022 was conducted. Articles on PE with a focus on MTX exclusively were included. Published and unpublished studies, from any world region, conducted with a qualitative, quantitative, or mixed‐methods design and focused on defined research questions, were eligible for inclusion. Broad inclusion criteria were used if a research paper on PE focused on MTX for people with RMDs (PE or patient engagement, self‐management, medication knowledge, or health literacy in patients). The reporting followed the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses ‐ Extension for Scoping Reviews (PRISMA‐ScR) checklist. Two independent reviewers performed standardized data extraction and synthesis.ResultsFrom 292 references identified, the total number of studies which met the inclusion criteria was relatively small (n = 14). The results identified that knowledge of MTX improves when education by nurses is provided.ConclusionThis scoping review showed that there is no universal worldwide strategy for MTX education of children/youths and adults with RMDs. However, PE regarding MTX can be delivered in different forms, resulting in better satisfaction and adherence. More randomized controlled trials with powered samples are required.

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“…PANLAR and ASAS/EULAR acknowledge the critical importance of guideline implementation efforts and the need for further research in this area. There is indeed a gap in incorporating effective implementation strategies into CPGs and understanding the factors which affect adoption of CPGs for rheumatic and musculoskeletal diseases, including axSpA [78 ]. In a study of axSpA guideline implementation, performed nearly 20 years ago, rheumatologists in 10 countries were sent a questionnaire to assess their agreement with the 2006 ASAS/EULAR recommendations for the treatment of AS, a precursor of ASAS/ EULAR.…”

Section: Guideline Implementation In Axial Spondyloarthritismentioning

confidence: 99%

Axial spondyloarthritis guidelines – aiming for maximum impact

Choufani,

Kay,

Ermann

2024

Current Opinion in Rheumatology

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Purpose of review This review discusses international clinical practice guidelines (CPGs) for axial spondyloarthritis (axSpA) focusing on methodology, guideline quality, and implementation. Recent findings The Assessment of SpondyloArthritis International Society/European Alliance of Associations for Rheumatology (ASAS/EULAR) and Pan-American League of Associations for Rheumatology (PANLAR) recently published axSpA CPGs and updates of the American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network (ACR/SAA/SPARTAN) and Asia-Pacific League of Associations for Rheumatology (APLAR) CPGs are expected. GRADE has emerged as the dominant framework for CPG development and has been used by three of the four international axSpA guidelines. Notable differences exist among these guidelines in the way that the recommendations are presented. Two of the four acknowledge the need for implementation strategies, but little detail about this is provided. The few studies that have evaluated the implementation of axSpA CPGs have identified poor adherence to recommendations on physical therapy/exercise and disease activity monitoring. Implementation science has identified many barriers and facilitators affecting guideline uptake, including those related to healthcare professionals and to the guidelines themselves. Creation of a tailored implementation plan simultaneously with the CPG is recommended. Summary While methodological rigor in the creation of evidence-based recommendations is the focus of CPG development, recommendations must be presented in a user-friendly format that makes them easy to apply. ‘Living guidelines’ could facilitate keeping content up to date. Implementation is critical for the success of a CPG and should be emphasized in future axSpA guideline updates. Further research is needed to better understand the factors impacting the successful implementation of axSpA CPGs.

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Implementation of recommendations in rheumatic and musculoskeletal diseases: considerations for development and uptake

Cited by 11 publications

References 27 publications

ASAS-EULAR recommendations for the management of axial spondyloarthritis: 2022 update

ASAS-EULAR recommendations for the management of axial spondyloarthritis: 2022 update

Towards a consensus for nurse education of methotrexate for people with rheumatic and musculoskeletal diseases: A scoping review

Axial spondyloarthritis guidelines – aiming for maximum impact

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