Proper management of rheumatoid arthritis in Latin America. What the guidelines say?

Abstract

To analyze characteristics of clinical practice guidelines (CPGs) for the management of rheumatoid arthritis (RA) developed in Latin American (LA) countries and to describe the knowledge, use, and barriers for their implementation perceived among LA rheumatologists, a comprehensive literature search including Medline, PubMed, Cochrane Library, LILACS and Scielo was performed. The Appraisal of Guidelines for Research and Evaluation (AGREE) instrument was applied for evaluation. A survey was sent to PANLAR members containing questions related to knowledge about guidelines, application of the recommendations, and difficulties in implementing CPGs. Eight guidelines were identified. Most guidelines were evidence based (62 %), but in only 37 % a systematic literature search was done. None of the guidelines included patients’ views and preferences, and only few of them stated an updating procedure. Funding body independence and disclosure of conflicts of interest were rarely reported. The survey was answered by 214 rheumatologists from all Latin American countries. Most rheumatologist reported knowledge and use of clinical guidelines, mainly international ones. In general, rheumatologist felt that guidelines apply to only a minority of patients seen in daily clinical practice. Limited access expensive drugs, suggested by the guidelines, was the most frequent barrier to guidelines implementation that was reported. A good number of guidelines on the treatment of rheumatoid arthritis have been developed in Latin America. Most of them are lacking some of the components recognized for high-quality clinical guidelines development. In spite that most rheumatologist know and apply guidelines, access to drugs is still a very important barrier to their implementation in Latin America.

EULAR points to consider for the management of difficult-to-treat rheumatoid arthritis

“…1 The updated European League Against Rheumatism (EULAR, from 2021, European Alliance of Associations for Rheumatology) recommendations for the management of RA 2 focusing on pharmacological therapy are similar to those developed by other international organisations. [3][4][5] Other recommendations and points to consider (PtCs) provide specific management support on cardiovascular disease (CVD) risk, 6 comorbidities, 7 imaging, 8 pain 9 and patient education. 10 Together with implementation of treat-to-target and tight control strategies, 2 11 specifically in the early phase of the disease, these have contributed to improved outcomes for the majority of patients with RA.…”

EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2019 update

“…Over the course of the decade, the development of new classification criteria for RA2; novel information on optimal clinical targets, such as the American College of Rheumatology (ACR)-EULAR remission definitions3; evolution of treatment algorithms and strategies4 5 and the advent of new drugs6 7 already necessitated two updates of the EULAR recommendations 8 9. The ACR, the Asian-Pacific League of Associations for Rheumatology (APLAR) and the Pan-American League of Associations for Rheumatology (PANLAR) have published similar guidance documents, although using slightly different approaches 10–12…”