Canadian Rheumatology Association Living Guidelines for the Pharmacological Management of Rheumatoid Arthritis With Disease-Modifying Antirheumatic Drugs

Glen S Hazlewood; Jordi Pardo Pardo; Cheryl Barnabe; Orit Schieir; Claire E H Barber; Laurie Proulx; Dawn P Richards; Peter Tugwell; Nick Bansback; Pooneh Akhavan; Claire Bombardier; Vivian Bykerk; Shahin Jamal; Majed Khraishi; Regina Taylor-Gjevre; J Carter Thorne; Arnav Agarwal; Janet E Pope

doi:10.3899/jrheum.220209

Canadian Rheumatology Association Living Guidelines for the Pharmacological Management of Rheumatoid Arthritis With Disease-Modifying Antirheumatic Drugs

J Rheumatol. 2022 Oct;49(10):1092-1099. doi: 10.3899/jrheum.220209. Epub 2022 Jul 15.

Authors

Glen S Hazlewood¹, Jordi Pardo Pardo², Cheryl Barnabe³, Orit Schieir⁴, Claire E H Barber³, Laurie Proulx⁵, Dawn P Richards⁵, Peter Tugwell⁶, Nick Bansback⁷, Pooneh Akhavan⁸, Claire Bombardier⁹, Vivian Bykerk¹⁰, Shahin Jamal¹¹, Majed Khraishi¹², Regina Taylor-Gjevre¹³, J Carter Thorne¹⁴, Arnav Agarwal¹⁵, Janet E Pope¹⁶

Affiliations

¹ G.S. Hazlewood, MD, PhD, Associate Professor, C. Barnabe, MD, MSc, Professor, C.E.H. Barber, MD, PhD, Associate Professor, Departments of Medicine and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, and Arthritis Research Canada, Vancouver, British Columbia, Canada; gshazlew@ucalgary.ca.
² J. Pardo Pardo, Ldo, Cochrane Musculoskeletal, University of Ottawa, Ottawa, Ontario, Canada.
³ G.S. Hazlewood, MD, PhD, Associate Professor, C. Barnabe, MD, MSc, Professor, C.E.H. Barber, MD, PhD, Associate Professor, Departments of Medicine and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, and Arthritis Research Canada, Vancouver, British Columbia, Canada.
⁴ O. Schieir, PhD, Department of Medicine, McGill University, Montreal, Quebec, Canada.
⁵ L. Proulx, B.Com, D.P. Richards, PhD, Canadian Arthritis Patient Alliance, Toronto, Ontario, Canada.
⁶ P. Tugwell, MD, Professor, Department of Medicine and School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada.
⁷ N. Bansback, PhD, Associate Professor, School of Population and Public Health, University of British Columbia, and Arthritis Research Canada, Vancouver, British Columbia, Canada.
⁸ P. Akhavan, MD, MSc, Division of Rheumatology, Mount Sinai Hospital, Toronto, Ontario, Canada.
⁹ C. Bombardier, MD, Professor, Division of Rheumatology, Mount Sinai Hospital, and Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
¹⁰ V. Bykerk, MD, Professor, Hospital for Special Surgery, New York, New York, USA.
¹¹ S. Jamal, MD, MSc, Clinical Associate Professor, Division of Rheumatology, University of British Columbia, Vancouver, British Columbia, Canada.
¹² M. Khraishi, MD, Clinical Professor, Department of Medicine, Memorial University of Newfoundland, St. Johns, Newfoundland and Labrador, Canada.
¹³ R. Taylor-Gjevre, MD, MSc, Professor, Division of Rheumatology, Department of Medicine, College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada.
¹⁴ J.C. Thorne, MD, Assistant Professor, The Centre of Arthritis Excellence and The Arthritis Program Research Group, Newmarket, Ontario, Canada.
¹⁵ A. Agarwal, MD, Division of General Internal Medicine, Department of Medicine, McMaster University, Hamilton, Ontario, Canada.
¹⁶ J.E. Pope, MD, MPH, Professor, Dept of Medicine, Western University, Schulich School of Medicine & Dentistry, London, Ontario, Canada.

PMID: 35840155
DOI: 10.3899/jrheum.220209

Abstract

Objective: To provide the initial installment of a living guideline that will provide up-to-date guidance on the pharmacological management of patients with rheumatoid arthritis (RA) in Canada.

Methods: The Canadian Rheumatology Association (CRA) formed a multidisciplinary panel composed of rheumatologists, researchers, methodologists, and patients. In this first installment of our living guideline, the panel developed a recommendation for the tapering of biologic and targeted synthetic disease-modifying antirheumatic drug (b/ts DMARD) therapy in patients in sustained remission using the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) approach, including a health equity framework developed for the Canadian RA population. The recommendation was adapted from a living guideline of the Australia & New Zealand Musculoskeletal Clinical Trials Network.

Results: In people with RA who are in sustained low disease activity or remission for at least 6 months, we suggest offering stepwise reduction in the dose of b/tsDMARD without discontinuation, in the context of a shared decision, provided patients are able to rapidly access rheumatology care and reestablish their medications if needed. In patients where rapid access to care or reestablishing access to medications is challenging, we conditionally recommend against tapering. A patient decision aid was developed to complement the recommendation.

Conclusion: This living guideline will provide contemporary RA management recommendations for Canadian practice. New recommendations will be added over time and updated, with the latest recommendation, evidence summaries, and Evidence to Decision summaries available through the CRA website (www.rheum.ca).

Keywords: GRADE; antirheumatic agents; clinical practice guideline; patient participation; rheumatoid arthritis.

Publication types

Research Support, Non-U.S. Gov't

MeSH terms

Antirheumatic Agents* / therapeutic use
Arthritis, Rheumatoid* / drug therapy
Biological Products* / therapeutic use
Canada
Humans
Rheumatology*

Substances

Antirheumatic Agents
Biological Products