Guidelines and recommendations developed and/or endorsed by the American College of Rheumatology
(ACR) are intended to provide guidance for particular patterns of practice and not to dictate the care of a particular
patient. The ACR considers adherence to the recommendations within this guideline to be voluntary,
with the ultimate determination regarding their application to be made by the physician in light of each
patient’s individual circumstances. Guidelines and recommendations are intended to promote beneficial or
desirable outcomes but cannot guarantee any specific outcome. Guidelines and recommendations developed
and endorsed by the ACR are subject to periodic revision as warranted by the evolution of medical knowledge,
technology, and practice. ACR recommendations are not intended to dictate payment or insurance decisions.
These recommendations cannot adequately convey all uncertainties and nuances of patient care.
The ACR is an independent, professional, medical and scientific society that does not guarantee, warrant, or
endorse any commercial product or service
Recommendations for treatment of early RA (disease duration ,6 months) patients are provided in Figures 2 and 3. An executive summary of these recommendations is available in Supplementary Appendix 5,
http://online library.wiley.com/doi/10.1002/acr.22783/abstract.Reasoning underlying the recommendations for the treatment of early RA. To achieve the above recommendations (Figure 2), the panel discussed several different PICO questions for early RA. The reasoning underlying the recommendations is described below.
PICO A.1. Despite the low quality evidence, the recommendation is strong because the Voting Panel concluded that the improved outcomes experienced by patients with established RA using a targeted approach should be generalizable to those with early RA (Figure
2). PICOs A.2 and A.3. Despite the low quality evidence, the recommendation is strong because 1) there is no evidence in favor of triple therapy in this setting, 2) DMARD monotherapy is generally more acceptable (i.e., easier to take, less cost to the patient) to early RA patients with low disease activity than DMARD combination regimens, and 3) DMARD monotherapy is generally better tolerated than combination DMARD therapy. The panel also voted that methotrexate (MTX) should be the preferred initial DMARD for most early RA patients.
PICOs A.4 and A.5. The recommendation is conditional because 1) the evidence is of low quality and the evidence for differences in side effects is imprecise, 2) there is little difference in the benefit of double DMARD therapy over monotherapy, and 3) triple therapy might be preferred by some patients who desire a more rapid short-term benefit(e.g., earlier resumption of work activities) and are willing to assume potential added risk.
PICOs A.6 and A.12. The recommendation is conditional because 1) the evidence is of low quality, and 2) although glucocorticoid therapy is effective as a shortterm (i.e., less than 3 months) therapy to “bridge” patients until realizing the benefits of DMARDs, this decision must be balanced by the lack of long-term glucocorticoid safety studies. The risk/benefit ratio of glucocorticoid therapy is favorable as long as the dose is low and the duration of therapy is short.
PICO A.7. The recommendation is strong despite the low quality of evidence because, for a patient failing DMARD monotherapy, clinical experience and indirect evidence support the benefits of adding these treatment options, and recommending no additional treatment is not an option. When deciding which therapy to use, considerations may include cost, comorbidities, burden of taking medications (i.e., 1 versus multiple, oral versus other routes) and side-effect pro- file. The panel also voted that biologic therapy should be used in combination with MTX, when possible, due to superior efficacy of this combination over biologic monotherapy.
PICOs A.8 and A.9. The recommendation is conditional because 1) the evidence is low quality, and 2) there are potential longer-term safety concerns related to tofacitinib that need more study, partly related to the shorter experience using tofacitinib.
PICOs A.10 and A.11. The recommendation is conditional because the evidence is of low quality because it is indirect, and the risk/benefit ratio of glucocorticoid therapy is favorable as long as the dose is low and duration of therapy is short.
Guidelines and recommendations developed and/or endorsed by the American College of Rheumatology(ACR) are intended to provide guidance for particular patterns of practice and not to dictate the care of a particularpatient. The ACR considers adherence to the recommendations within this guideline to be voluntary,with the ultimate determination regarding their application to be made by the physician in light of eachpatient’s individual circumstances. Guidelines and recommendations are intended to promote beneficial ordesirable outcomes but cannot guarantee any specific outcome. Guidelines and recommendations developedand endorsed by the ACR are subject to periodic revision as warranted by the evolution of medical knowledge,technology, and practice. ACR recommendations are not intended to dictate payment or insurance decisions.These recommendations cannot adequately convey all uncertainties and nuances of patient care.The ACR is an independent, professional, medical and scientific society that does not guarantee, warrant, orendorse any commercial product or serviceRecommendations for treatment of early RA (disease duration ,6 months) patients are provided in Figures 2 and 3. An executive summary of these recommendations is available in Supplementary Appendix 5, http://online library.wiley.com/doi/10.1002/acr.22783/abstract.Reasoning underlying the recommendations for the treatment of early RA. To achieve the above recommendations (Figure 2), the panel discussed several different PICO questions for early RA. The reasoning underlying the recommendations is described below. PICO A.1. Despite the low quality evidence, the recommendation is strong because the Voting Panel concluded that the improved outcomes experienced by patients with established RA using a targeted approach should be generalizable to those with early RA (Figure 2). PICOs A.2 and A.3. Despite the low quality evidence, the recommendation is strong because 1) there is no evidence in favor of triple therapy in this setting, 2) DMARD monotherapy is generally more acceptable (i.e., easier to take, less cost to the patient) to early RA patients with low disease activity than DMARD combination regimens, and 3) DMARD monotherapy is generally better tolerated than combination DMARD therapy. The panel also voted that methotrexate (MTX) should be the preferred initial DMARD for most early RA patients. PICOs A.4 and A.5. The recommendation is conditional because 1) the evidence is of low quality and the evidence for differences in side effects is imprecise, 2) there is little difference in the benefit of double DMARD therapy over monotherapy, and 3) triple therapy might be preferred by some patients who desire a more rapid short-term benefit(e.g., earlier resumption of work activities) and are willing to assume potential added risk. PICOs A.6 and A.12. The recommendation is conditional because 1) the evidence is of low quality, and 2) although glucocorticoid therapy is effective as a shortterm (i.e., less than 3 months) therapy to “bridge” patients until realizing the benefits of DMARDs, this decision must be balanced by the lack of long-term glucocorticoid safety studies. The risk/benefit ratio of glucocorticoid therapy is favorable as long as the dose is low and the duration of therapy is short. PICO A.7. The recommendation is strong despite the low quality of evidence because, for a patient failing DMARD monotherapy, clinical experience and indirect evidence support the benefits of adding these treatment options, and recommending no additional treatment is not an option. When deciding which therapy to use, considerations may include cost, comorbidities, burden of taking medications (i.e., 1 versus multiple, oral versus other routes) and side-effect pro- file. The panel also voted that biologic therapy should be used in combination with MTX, when possible, due to superior efficacy of this combination over biologic monotherapy. PICOs A.8 and A.9. The recommendation is conditional because 1) the evidence is low quality, and 2) there are potential longer-term safety concerns related to tofacitinib that need more study, partly related to the shorter experience using tofacitinib. PICOs A.10 and A.11. The recommendation is conditional because the evidence is of low quality because it is indirect, and the risk/benefit ratio of glucocorticoid therapy is favorable as long as the dose is low and duration of therapy is short.
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