The 2021 ACR RA Guidelines are released!

*It is only for medical professionals to read for reference.
What has been updated for 6 years? In June 2021, the American College of Rheumatology (ACR) issued a guideline for the diagnosis and treatment of rheumatoid arthritis (RA), which is the first version of the guideline that was updated 6 years after the 2015 guideline
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This guide covers the use of disease-improving anti-rheumatic drugs (DMARDs), including traditional synthetic DMARDs (csDMARDs), biological DMARDs (bDMARDs) and targeted synthetic DMARDs (tsDMARDs), the use of glucocorticoids, and certain special populations (ie People with liver disease, heart failure, lymphoproliferative disease, previous severe infection and non-tuberculous mycobacterial lung disease are recommended for the use of DMARDs
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The guidelines form a total of 14 general principles and 44 specific recommendations (7 highly recommended and 37 conditional recommendations)
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Let's take a look at the specific content! Screenshot of the guideline 14 general principles The early evaluation, diagnosis and treatment of RA is an important general principle in management
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This recommendation is for the general RA patient population and assumes that patients have no contraindications to the drug options under consideration
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Table 1 General Principles What has been specifically updated? 1.
DMARDs treatment is recommended for patients with moderate to high disease activity who have not received DMARDs: the guidelines strongly recommend methotrexate monotherapy; patients with low disease activity who have not received DMARDs: the guidelines recommend the use of hydroxychloroquine>sulfasalazine>methamine Pterin> leflunomide; in terms of hormone use, the guidelines believe that no hormone is used> short-term (<3 months)> long-term (≥3 months) use
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Table 2 Recommendations for treatment of DMARDs 2.
How to use methotrexate? For initial treatment patients, the guidelines recommend the use of methotrexate: oral> subcutaneous injection, initial/titrated dose ≥15mg/week
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Table 3 Recommendations for methotrexate treatment 3.
Recommendations for patients who do not meet the standard.
The guidelines recommend low disease activity as the treatment goal
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Table 4 Recommendations for treatment adjustments for patients who have not reached the standard 4.
Recommendations for reduction and discontinuation of DMARDs.
For DMARDs reduction and discontinuation, the guidelines recommend: continue to use the current dose> reduction> gradual discontinuation> sudden discontinuation Table 5 Recommendations for reduction and discontinuation of DMARDs 5.
Special How do people use medicine? Special populations include subcutaneous nodules, lung disease, heart failure, lymphoproliferative disease, hepatitis B, non-alcoholic fatty liver, persistent hypogammaglobulinemia without infection, non-tuberculous mycobacterial lung disease, and severe RA patients with a history of infection
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Table 6 Recommendations for 2021 vs 2015 ACR Guidelines by Specific Groups The above is the main content of the 2021 version of the guidelines.
After six years, the guidelines are updated again.
What is the difference from the 2015 version of the guidelines? First of all, the 2015 guidelines recommend the use of methotrexate when treating patients with low and moderate/high disease activity with csDMARDs, while this update recommends the use of hydroxychloroquine or sulfasalazine for patients with low disease activity Treatment
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Second, the 2015 guidelines recommend a gradual reduction in DMARDs for patients in remission
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In this update, for patients with low disease activity or low remission rate, in the absence of data on when and how best to reduce the dose, recommendations for reduction are proposed
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The expert panel recommends that if patients want to reduce DMARDs, they can consider reducing the dose carefully
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However, patients should be closely evaluated during any drug reduction process, and if recurrence occurs, the previous protocol should be resumed immediately
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 Finally, the 2021 guidelines update several recommendations against the use of glucocorticoid therapy
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Because it is recognized that it is difficult to reduce glucocorticoids, it will lead to long-term adverse use, and more and more evidences show that glucocorticoids have a negative impact on the long-term prognosis of patients, including infections of RA and other rheumatic diseases, osteoporosis and The risk of cardiovascular disease
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 In summary, the update of this guideline includes recommendations for initial and adjusted treatment of DMARDs in RA patients
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It also emphasizes the importance of minimizing the use of glucocorticoids
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With the subsequent release of new data, ACR will further update the guidelines
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 References: [1]Fraenkel L, Bathon JM, England BR,et al.
2021 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis[J].
Arthritis Care Res (Hoboken).
2021 Jun 8.
doi: 10.
1002/acr .
24596.
Epub ahead of print.