Google Scholar. Guo J, Cheng C, Yan W, Xu G, Feng J, Wang T, Chen CS, Qin X. Consequently we did not register our protocol; however, several other recent systematic reviews have evaluated different guidelines using similar approaches to our own, such as the report by Jollife et al. Firmly embedded in clinical practice – users lead the proposal, selection and development of all guideline topics – we choose new areas, areas where there is clinical uncertainty, where mortality or morbidity can be reduced. Guidelines were sometimes intended to provide information for a broader range of readers: 6 guidelines [19,20,21, 23, 29, 34] included a range of administrative staff including commissioners and payers of healthcare; 7 guidelines [14, 19,20,21, 23, 29, 34] included patients and in some cases patient groups. The importance of assessing disability was considered by most guidelines. Ann Rheum Dis. In 13/22 guidelines there was consideration of the relative benefits and risks of oral and subcutaneous methotrexate [14, 17, 20,21,22,23,24, 27, 29, 31,32,33, 35]; however, the approach taken to this issue varied considerably and there was no obvious consensus across guidelines about when best to use parenteral methotrexate. The limitations of clinical guidelines have been described in detail [49,50,51,52]. Accessed 25 Mar 2018. Correspondence to We did not set out to produce any single optimal set of recommendations for RA management from our analyses of these guidelines. 2016;34(5 Suppl 101):S45–8. Misra R, Sharma BL, Gupta R, Pandya S, Agarwal S, Agarwal P, Grover S, Sarma P, Wangjam K. Indian rheumatology association consensus statement on the management of adults with rheumatoid arthritis. Some of these guidelines had specific structures which were replicated across questions; for example the Canadian guideline [21] for each question included the recommendation, the supporting evidence and the barriers to implementation. Firstly, the recommendations in the guidelines are broadly similar, though they differ in some points of detail; for example the use of combinations of conventional DMARDs. 2011;63:1142–9. In addition many guidelines emphasised the importance of minimising disability, minimising progressive joint damage and maximising quality of life, though these were less explicit management goals. Google Scholar. Munn Z, Peters MDJ, Stern C, Tufanaru C, McArthur A, Aromataris E. Systematic review or scoping review? Secondly disease activity should be regularly monitored using composite indices such as DAS28, which relates to our initial aim which was our initial specific question. Accessed 25 Mar 2018. Eight other guide guidelines included some systematic reviews [15,16,17, 21, 24, 28, 30, 32, 35, 38] within them, including systematically assessing other guidelines, and one other guideline formally used existing published systematic reviews to assess each question they considered [30]. PubMed  One guideline, from England, recommended initial combinations of conventional DMARDs [29], though it did not specify which drugs to use. PubMed Central  Two guidelines recommend aiming to suppress inflammation: the British Columbia guideline [18] concluded that the objective of treatment is to “suppress all inflammation”, implying this is joint inflammation; the British Society For Rheumatology established RA guideline [19] recommended “suppressing inflammation” indicating this was to limit disease progression. Those guidelines which consider the use of NSAIDs invariably focus on minimising exposure to these treatments. CMAJ. As PRISMA does not specifically include systematic reviews of guidelines we did not pre-register our protocol; this was omitted in other systematic reviews of guidelines [12]. Guidelines for the management of rheumatoid arthritis (RA) produced by expert groups based on assessments of the research evidence have been produced for over 25 years [1,2,3,4]. ACR Convergence is not just another meeting – it’s where inspiration and opportunity unite to create an unmatched educational experience. Some of these guidelines also had specific structures replicated across themes; for example the English (Royal College of Physicians) guideline [29] had summaries of the evidence, sections from evidence to recommendations and then one or more recommendations for each of the themes it considered. Misra DP, Agarwal V, Sharma A, Wakhlu A, Negi VS. 2016 update of the EULAR recommendations for the management of rheumatoid arthritis: a utopia beyond patients in low/middle income countries? In most cases, they are prescribed when conventional DMARDs have not worked. Finally, systematic reviews of guidelines are not one of the current PRISMA extensions [53] though we anticipate they will be included in subsequent updates. Clin Exp Rheumatol. Specific Combinations of conventional DMARDS were recommended by 12/22 guidelines [14, 15, 17, 21, 23,24,25,26,27,28, 31, 33]: these combinations comprised methotrexate with sulfasalazine and hydroxychloroquine or methotrexate with leflunomide in 9 guidelines; 2 guidelines omitted leflunomide from combinations [23, 33] and one guideline recommended chloroquine instead of hydroxychloroquine [31]. All guidelines recommend treating active RA. Article  2005;32:2410–5. 2006;45(Suppl 2):7–22. CAS  September 2012. https://www2.gov.bc.ca/gov/content/health/practitioner-professional-resources/bc-guidelines/rheumatoid-arthritis. There has been correspondence about this particular aspect of the EULAR guidelines [46, 47]. Arthritis Care Res. 2008;3(Suppl):S1–S16. Martin NH, Ibrahim F, Tom B, Galloway J, Wailoo A, Tosh J, Lempp H, Prothero L, Georgopoulou S, Sturt J, Scott DL, TITRATE Programme Investigators. These included two European League Against Rheumatism (EULAR) guidelines, which provided general guidance and guidance of treat to target [22, 34], and four different guidelines from the United Kingdom [6, 7, 24, 25], which were produced by various groups at different times and worked from varying perspectives. Cookies policy. Google Scholar. BMJ Open. volume 3, Article number: 42 (2019) We sought evidence that individual guidelines had followed nationally or internationally accepted quality methods in their development; we did not assess their quality as part of this report. All data generated or analysed during this study are included in this published article. The ACR guidance makes the strongest recommendation on this point. We have included general ones. Rheumatoid arthritis (RA) is the most common type of chronic inflammatory arthritis. These recommendations are summarised in Table 3. Three dealt with early RA, one established RA and 18 all patients. Bykerk VP, Akhavan P, Hazlewood GS, Schieir O, Dooley A, Haraoui B, Khraishi M, Leclercq SA, Légaré J, Mosher DP, Pencharz J, Pope JE, Thomson J, Thorne C, Zummer M, Bombardier C, Canadian Rheumatology Association. 1994;41:86–9. Fleming PS, Koletsi D, Pandis N. Blinded by PRISMA: are systematic reviewers focusing on PRISMA and ignoring other guidelines? For example the Scottish Guidelines suggest using the lowest NSAID dose compatible with symptom relief, and indicate that treatment should be reduced and if possible withdrawn as soon as possible and that gastro-protection should be included when using them. There is also relatively little overall consensus about treating moderately active RA. By including their personal experiences with different therapies, including their effectiveness, ease of use and side effects, the recommendations reflect the ACR’s goal of shared decision making between the rheumatologist and patient,” says Principal Investigator Liana Fraenkel, MD, MPH, Professor Adjunct in the Division of Rheumatology, Allergy and Immunology at Yale University School of Medicine. None of the guidelines specifically recommended one composite index over another. “Despite the many treatment recommendations included in this guideline, there are a number of remaining questions to address in more frequent, future updates. Terms and Conditions, PubMed  Thirteen guidelines made specific recommendations about treating moderate disease. British Society for rheumatology and British health professionals in rheumatology guideline for the management of rheumatoid arthritis (the first two years). Luqmani R, Hennell S, Estrach C, Basher D, Birrell F, Bosworth A, Burke F, Callaghan C, Candal-Couto J, Fokke C, Goodson N, Homer D, Jackman J, Jeffreson P, Oliver S, Reed M, Sanz L, Stableford Z, Taylor P, Todd N, Warburton L, Washbrook C, Wilkinson M, British Society for Rheumatology, British Health Professionals in Rheumatology Standards, Guidelines and Audit Working Group. These principles relate to another of our specific questions. Indian J Rheumatol. Our inclusion criteria comprised: (a) publications that identified themselves as guidelines; (b) guidelines that provided recommendations on the general management of RA; (c) guidelines that included a range of different drug treatments; (d) guidelines published from January 2000 to January 2017; (e) guidelines published in English. Secondly, although guidelines deal with the same issue, they bring together different groups of experts and it is likely the production of guidelines enhances clinical practice. statement and 1997;11:157–79. Guidance for authors when choosing between a systematic or scoping review approach. J Clin Epidemiol. The data included: (a) year of publication; (b) format (who was involved); (c) quality method followed; (d) systematic review of evidence; (e) patient groups considered; (f) area of management included; (g) composite activity assessments; (h) prognostic assessments; (i) treatment targets; (j) and range of treatments considered. Grade (Grading of Recommendations Assessment, Development and Evaluation). These perspectives were from expert groups who had considered the same evidence in detail and they show the divergence of expert views when assessing clinical research findings. The funders had no role in the study design, data collection and analysis, data interpretation, the writing of the manuscript or the decision to submit the manuscript for publication. Rheumatol Int. The 21 guidelines considering early RA all recommended starting disease modifying drugs (DMARDs) as soon as possible; methotrexate was recommended for most patients. Gaujoux-Viala C, Gossec L, Cantagrel A, Dougados M, Fautrel B, Mariette X, Nataf H, Saraux A, Trope S, Combe B, French Society for Rheumatology. BMJ. 2018;8:e018791. The guidelines including prognostic assessments all recommended considering more intensive treatment with conventional DMARDs and biologic DMARDs in those patients with poor prognostic features. A study of 609 rheumatoid arthritis patients and 609 non-rheumatoid arthritis patients, all over age 18, revealed rheumatoid arthritis patients have higher rates in 11 infection categories (95% CI, 1.41 to 1.65). People should also have rapid access to specialist care if their condition suddenly worsens. The frequency of review will reflect the timing of new clinical information. The overall impact of the guidelines is difficult to establish. Scott DL. The British guidelines for established RA did not consider glucocorticoids (steroids). A systematic review of guidelines for managing rheumatoid arthritis. Article  Many others focus on single drugs or treatment modalities including surgery. National Collaborating Centre for Chronic Conditions (UK). Expert Spotlight, 2020 Guideline for the Management of Rheumatoid Arthritis (RA), https://www.rheumatology.org/Annual-Meeting, Register for reporter access to contact details, Newswise Live - 2011;11:15. The most recent EULAR guidance is particularly uncertain about its value. 2012;39:1559–82. Consequently multiple guidelines appear to be needed. Those guidelines that consider them recommend their use as an alternative to biologics in some patients with established RA. Google Scholar. The recommendations varied more widely on how to do this and 10/22 guidelines recommended regularly assessing disability [15, 17, 21, 25,26,27, 29, 31,32,33]: 9 of these recommended using the Health Assessment Questionnaire (HAQ) [44]; the Canadian guidelines did not specifically suggest assessing HAQ regularly [21]. Report of a Joint Working Group of the British Society for Rheumatology and the Research Unit of the Royal College of Physicians. BMJ. Rheumatoid Arthritis (RA) is an autoimmune disorder in which a person’s immune system attacks the body’s tissues. However, EULAR did not exclude their use, and mention them briefly. https://www.agreetrust.org. It has been written using up to date published research and evidenced based medicine. Accessed 25 Mar 2018. Adalimumab, etanercept, inflfliximab, certolizumab pegol, golimumab, tocilizumab and abatacept for rheumatoid arthritis not previously treated with DMARDs or after conventional DMARDs only have failed. All 20 indicated they were mainly aimed at clinicians; the Australian (Royal Australian College of General Practitioners) indicated their guidelines [16] were specifically intended for GPs. Smolen JS, Landewé R, Bijlsma J, Burmester G, Chatzidionysiou K, Dougados M, Nam J, Ramiro S, Voshaar M, van Vollenhoven R, Aletaha D, Aringer M, Boers M, Buckley CD, Buttgereit F, Bykerk V, Cardiel M, Combe B, Cutolo M, van Eijk-Hustings Y, Emery P, Finckh A, Gabay C, Gomez-Reino J, Gossec L, Gottenberg JE, JMW H, Huizinga T, Jani M, Karateev D, Kouloumas M, Kvien T, Li Z, Mariette X, McInnes I, Mysler E, Nash P, Pavelka K, Poór G, Richez C, van Riel P, Rubbert-Roth A, Saag K, da Silva J, Stamm T, Takeuchi T, Westhovens R, de Wit M, van der Heijde D. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2016 update. However, the balance of opinion in these various guidelines favours the use of combinations of conventional DMARDs in some patients. 2009;48:436–9. (the TITRATE trial): study protocol for a randomised controlled trial. The American College of Rheumatology (ACR) guideline commissioned [14] detailed systematic reviews that were published as an appendix. As the various updates of ACR and EULAR guidelines have high citation rates on bibliometric systems it seems likely they are used by many groups. 2005;23(5 Suppl 39):S14–8. The manuscript, containing the full list of recommendations and supporting evidence, is currently under review and is anticipated to be simultaneously published in Arthritis Care & Research and Arthritis & Rheumatology by fall 2020, pending completion of peer review. For more information about the meeting, visit https://www.rheumatology.org/Annual-Meeting, or join the conversation on Twitter by following the official hashtag (#ACR20). When there were several versions of guidelines from the same organisation, only the latest guideline was included. Thirdly, what is the impact of these guidelines on clinical practice? There were variable levels of patient involvement; 12/22 guidelines specified there was patient involvement [14,15,16, 19,20,21,22,23,24, 31, 34]. We systematically reviewed current guidelines for managing rheumatoid arthritis (RA) to evaluate their range and nature, assess variations in their recommendations and highlight divergence in their perspectives. The EULAR guidelines also provide an extensive commentary on the divergence of expert opinion on this issue, highlighting potential toxicities and difficulties dissociating the impact of methotrexate, short-term glucocorticoids (steroids) and other conventional DMARDs in combinations. A change from past recommendations to escalate to triple therapy before starting a biologic. Thirdly, we have only provided a narrative assessment of them. Biologics 'My Story Animation' Biologics Animation created by Pfizer. About the American College of Rheumatology. Event in Progress, Newswise Chatterjee A, Bhattacharyya O, Persaud N. How can Canadian guideline recommendations be tested? We also followed methods recommended for reviews of systematic reviews [11] and approaches taken in previous systematic reviews of guidelines [12, 13]. There was less unanimity about treating moderately active disease. Reumatol Clin. Ann Rheum Dis. The European League Against Rheumatism (EULAR) developed its first recommendations for the management of rheumatoid arthritis (RA) with synthetic and biological disease-modifying antirheumatic drugs (DMARDs) in 2010.1 They summarised the state of the art and provided rheumatologists, patients, payers and other stakeholders with the evidence-based views of European … One important role of guidelines is to suggest potential future research questions. Article  van Riel PL, Renskers L. The disease activity score (DAS) and the disease activity score using 28 joint counts (DAS28) in the management of rheumatoid arthritis. PubMed Central  Lau CS, Chia F, Harrison A, Hsieh TY, Jain R, Jung SM, Kishimoto M, Kumar A, Leong KP, Li Z, Lichauco JJ, Louthrenoo W, Luo SF, Nash P, Ng CT, Park SH, Suryana BP, Suwannalai P, Wijaya LK, Yamamoto K, Yang Y, Yeap SS, Asia Pacific League of Associations for Rheumatology. Google Scholar. 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Guidelines in more detail and overlooked some of these guidelines, such as Scottish! Person’S immune system attacks the body’s tissues not usually prescribe these treatments thirdly, is!