World-first rheumatology guidelines employing ‘living evidence’ methodology

The introduction of targeted therapies, including biological and targeted synthetic diseasemodifying antirheumatic drugs (b/tsDMARDs), has had a major impact on the management of inflammatory arthritis, including rheumatoid arthritis (RA), psoriatic arthritis (PsA) and axial spondyloarthritis (AxSPA).

While b/tsDMARDs are very effective, there are risks of side effects, especially infections, and they are often perceived as burdensome by patients. They are also very expensive and contribute significantly to the overall cost of PBS-funded medications in Australia.

Understanding the cost effectiveness in relation to quality of use is a strategic priority. One option is dose tapering and discontinuation of b/tsDMARDs in patients who have achieved a low disease activity state or remission, which would help reduce the economic impact of the drugs, as well as provide patients an option in balancing the benefits and risks of longterm therapy. Professor Rachelle Buchbinder AO (pictured) has driven the partnership of Monash Cabrini Department of Musculoskeletal Health and Clinical Epidemiology and the Australia and New Zealand Musculoskeletal (ANZMUSC) Clinical Trial Network with the Australian Rheumatology Association and involving Cochrane Musculoskeletal, which has recently led to the development of national living guidelines which has made recommendations on this topic. Living guidelines incorporate new evidence for individual recommendations as soon as it becomes available.

The guideline made conditional recommendations in favour of reducing the dose of b/tsDMARDs in people with RA or AxSpA who have achieved a stable low disease activity state. However, the impact of an inflammatory arthritis disease flare and the likelihood of recapturing disease control with resumption of the previous dose of b/tsDMARD are likely to be important considerations. An individual shared decision-making approach that considers individual circumstances and preferences was recommended. It also made a conditional recommendation against dose modification in people with PsA due to the relative lack of evidence. Abrupt discontinuation of b/tsDMARDs was not recommended in any of the three diseases.

The NHMRC-endorsed recommendations are part of the Australian Living Guideline for the Pharmacological Management of Inflammatory Arthritis. It is the world’s first rheumatology guideline to employ ‘living evidence’ methodology, in which individual recommendations are updated in near real-time as new evidence emerges, supporting rapid changes in clinical practice. All updates to the recommendations, including the addition of new trial evidence, are published immediately via the web-based application MAGICapp (https://app.magicapp. org/#/guidelines) and can be viewed at www.mskguidelines.org.

anti-rheumatic drugs inflammatory