EULAR Guidelines Updated for Early Arthritis

Janis C. Kelly

January 12, 2017

Updated recommendations from the European League Against Rheumatism (EULAR) for the management of early arthritis put renewed emphasis on early intervention, preventive lifestyle measures, and careful clinical examination, rather than reliance on ultrasound or advanced imaging.

"Compared with the 2007 recommendations and based on research data, we have, even more than before, focused on early referral and early [disease-modifying antirheumatic drug] start for those who need it, since we have learned that this may improve outcome," coauthor Robert Landewe, MD, from the Department of Clinical Immunology & Rheumatology, Amsterdam Rheumatology, and Zuyderland Medical Centre, Heerlen, the Netherlands, told Medscape Medical News.

"We have added words on prevention of arthritis now: stop smoking, avoid obesity, perform good dental care," he continued. "We have focused on clinical examination and downplayed the role of ultrasound, [magnetic resonance imaging (MRI)], and other biomarkers in making an appropriate diagnosis. And we have put a warning on careless and unlimited glucocorticoid use, since new evidence points to side effects of long-term use."

Dr Landewe was part of a EULAR expert committee tasked with updating the 2007 guidelines based on analysis of evidence in the literature and on expert opinion. The committee included 20 rheumatologists, two patients, and one healthcare professional representing 12 European countries. The updated guidelines were published online December 15 in the Annals of Rheumatic Diseases.

After defining the target population and formulating a definition of management, the committee selected the research questions to serve as the basis for a systematic literature research. Draft recommendations were evaluated on the basis of categories of evidence. Committee votes determined strength of the recommendations and level of agreement for three overarching principles and 12 recommendations for managing early arthritis. Topics included recognition of arthritis, referral, diagnosis, prognostication, treatment (information, education, and pharmacological and nonpharmacological interventions), monitoring, and strategy.

Dr Landewe said the revision includes increased emphasis on patient communication. "Treatment is more than providing drugs. Education is key, and the allied health professional is key in providing education. More than in 2007, the communication with the patient as a partner rather than as a recipient of care has been brought forward," Dr Landewe said.

Another notable change was deleting MRI from recommendations for routine use. Dr Landewe said, "Arthritis is a clinical finding that is associated with patients' complaints. All evidence for drug treatment has been based on clinically detecting arthritis. Multiple studies claiming a better sensitivity for MRI/ultrasound have not convinced us, since the back side of using MRI/ultrasound is lower specificity." He noted that the situation for ultrasound is murkier than for MRI, but said that may turn out to be inappropriate in the end.

With regard to timing of treatment, Dr Landewe said recent data support the view that patients should be started on DMARDs as early as possible, ideally within 3 months of symptom onset.

The update also further enshrines treat-to-target as the principle that should guide clinical decisions. This was taken to mean treatment "to the absence of signs and symptoms of significant inflammatory disease activity."

However, Dr Landewe cautioned that the other recommendations and overarching principles also hold. "So, the patient should agree, comorbidity should principally allow such a strategy, adverse events should be taken into consideration, and so forth," he said.

The recommendations also include additional emphasis on outcomes monitoring, which might mark a change in usual practice for some clinicians. "I am afraid current practice all too often does not include such monitoring principles to date. But recommendation 9 points to their importance: If you believe in treat-to-target, the first adagium is 'measure,' " Dr Landewe said.

The updated EULAR recommendations for managing early RA are largely consistent with the standards of care for managing these patients in the United States and throughout the world, according to Kenneth Saag, MD, the Jane Knight Lowe Professor, Division of Clinical Immunology and Rheumatology; vice chair, Department of Medicine; and director, Center for Education and Research on Therapeutics, University of Alabama at Birmingham. "These are evidence-based recommendations that also incorporate expert opinion, and I think they are highly logical," said Dr Saag, who was not involved in the EULAR expert committee.

"The challenge, of course, with early arthritis is the difficulty in knowing what it might become, which produces some tension between the risks of over-treating and under-treating," Dr Saag told Medscape Medical News. "You don't want to expose people to unnecessary treatment-associated risks, but you also don't want to allow a disease to go unchecked. There is emerging evidence that early aggressive intervention in patients expressing the earliest forms of some rheumatoid diseases might attenuate, if not abrogate, progression to full-scale disease. Unfortunately, all our therapies have some risk, particularly around infection or toxicity, so we have to exercise caution in when to intercede with which agent."

Dr Saag noted that one difference from common clinical practice involves hydroxychloroquine, which is a drug "we might often use when there is some degree of uncertainty," but was not included in the EULAR recommendations.

The study was supported by an unrestricted grant from the European League Against Rheumatism. Dr Landewe has received honoraria and/or research grants from AbbVie, Ablynx, Amgen, AstraZeneca, Bristol-Myers Squibb, Celgene, Janssen, Galapagos, GlaxoSmithKline, Novartis, Novo-Nordisk, Merck, Pfizer, Roche, Schering-Plough, TiGenix, and UCB. Dr Saag has disclosed no relevant financial relationships.

Ann Rheum Dis. Published online December 15, 2016. Full text

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