An Australian Living Guideline for the Pharmacological Management of Inflammatory Arthritis

Published by Dr Vanessa Glennon on Jan 2, 2024

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Disclaimer

These clinical guidelines have been informed by the highest quality evidence available at the time of compilation. Accordingly, the parties involved in the development of these guidelines shall have no liability to any users of the information contained in this publication for any loss or damage, cost or expense incurred or arising from reliance on the information contained in this publication.
 

Sponsors

An Australian Living Guideline for the Pharmacological Management of Inflammatory Arthritis is being produced by the Australia and New Zealand Musculoskeletal (ANZMUSC) Clinical Trials Network, the Australian Rheumatology Association (ARA) and Cochrane Musculoskeletal. From 2019 to 2022 guideline development was funded by the Australian Government Department of Health through the Value in Prescribing (VIP) bDMARDs Program Grant, awarded to the Targeted Therapies Alliance led by NPS MedicineWise. Current support is being provided by the NHMRC Australia and New Zealand Musculoskeletal (ANZMUSC) Clinical Trials Network Centre of Research Excellence (2023-27), Cochrane Musculoskeletal, and the Victorian Government via the Australian Living Evidence Consortium.

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Abstract

An Australian Living Guideline for the Pharmacological Management of Inflammatory Arthritis seeks to present the best available, current scientific evidence to assist decision making in the pharmacological management of the most common forms of IA, namely rheumatoid arthritis (RA), axial spondyloarthritis (axSpA) and psoriatic arthritis (PsA).  The guideline offers recommended courses of action subject to clinical judgement and patient preferences.  Topics and questions identified as having highest clinical relevance to medical practitioners who treat IA are being prioritised. These questions include choice of DMARD, switching, combination therapy, down-titration of treatment and perioperative DMARD use, as well as the management of other medications such as opioids, glucocorticoids and vaccination.  As a living guideline, questions will continue to be addressed, new recommendations developed, and existing recommendations updated on an ongoing basis.

Language

en

PICOS

PICO 1.1

Population
Rheumatoid arthritis patients with low disease activity
Intervention
Dose reduction of csDMARDs
Comparator
Continuation of csDMARDs
Outcomes

PICO 1.1

Population
Adults with rheumatoid arthritis experiencing disease flare, and receiving DMARD therapy
Intervention
Glucocorticoids
Comparator
No glucocorticoids
Outcomes

PICO 1.1

Population
People with inflammatory rheumatic diseases on immunomodulatory therapies
Intervention
COVID vaccines (2 doses: AstraZeneca, Pfizer, Moderna & Novavax)
Comparator
Placebo
Outcomes

PICO 1.1

Population
Adults with rheumatoid arthritis
Intervention
Opioids
Comparator
Placebo
Outcomes

PICO 1.2

Population
Rheumatoid arthritis patients with low disease activity
Intervention
Discontinuation of csDMARDs
Comparator
Continuation of csDMARDs
Outcomes

PICO 1.2

Population
Adults with rheumatoid arthritis experiencing disease flare, and receiving DMARD therapy
Intervention
Glucocorticoid therapy (dexamethasone, DEXA i.v. infusion) as an adjunct to DMARD therapy
Comparator
Different glucocorticoid therapy (methylprednisolone, MP i.v. infusion) as an adjunct to DMARD therapy
Outcomes

PICO 2.1

Population
Adults with rheumatoid arthritis receiving DMARD therapy
Intervention
Low dose glucocorticoid (GC) therapy (5 to 10mg daily oral prednisolone and 120mg monthly intramuscular depomedrone for 1-2 years treatment duration) as an adjunct to DMARD therapy (MTX, SSZ, IM/parenteral gold, penicillamine, azathioprine, ciclosporin)
Comparator
DMARD therapy alone (placebo or no GC)
Outcomes

PICO 2.1

Population
Rheumatoid arthritis patients with low disease activity
Intervention
Dose reduction of b/tsDMARDs
Comparator
Continuation of b/tsDMARDs
Outcomes

PICO 2.1

Population
People with inflammatory rheumatic diseases on immunomodulatory therapies (Solid Organ Transplant Recipients)
Intervention
COVID-19 third-dose vaccines (AstraZeneca, Pfizer, Moderna & Novavax)
Comparator
Placebo
Outcomes

PICO 2.1

Population
Adults with axial spondyloarthritis
Intervention
Opioids
Comparator
Different opioids and analgesic comparators were used across the studies: Chang 2013 compared tramadol 37.5 mg/paracetamol 325 mg combination tablets (Ultracet®) one tablet twice a day, plus aceclofenac (NSAID) tablet per oral 100 mg twice a day with placebo plus 100 mg aceclofenac (NSAID) tablet per oral twice a day; Murphy 1978 compared dihydrocodeine tartrate (one 30mg tablet, DF-118®), taken 3-4 times daily for a period of 4 to 14 days with fenoprofen (one 200 mg capsule) and paracetamol (one 500 mg tablet), taken 3 to 4 times daily for a period of 4 to 14 days.
Outcomes

PICO 2.2

Population
Rheumatoid arthritis patients with low disease activity
Intervention
Discontinuation
Comparator
Continuation
Outcomes

PICO 2.2

Population
People with inflammatory rheumatic diseases on immunomodulatory therapies (Healthy Population)
Intervention
COVID-19 third-dose vaccines (AstraZeneca, Pfizer, Moderna & Novavax)
Comparator
Placebo
Outcomes

PICO 2.3

Population
Rheumatoid arthritis patients with low disease activity - DUPLICATE DURING UPDATE (September 2023)
Intervention
Dose reduction
Comparator
Continuation
Outcomes

PICO 2.4

Population
Rheumatoid arthritis patients with low disease activity - DUPLICATE DURING UPDATE (September 2023)
Intervention
Discontinuation
Comparator
Continuation
Outcomes

PICO 3.1

Population
Axial spondyloarthritis patients with low disease activity
Intervention
Dose reduction
Comparator
Continuation
Outcomes

PICO 3.1

Population
Adults with rheumatoid arthritis initiating/adding/switching DMARD therapy (Comparison 1)
Intervention
Bridging GC + DMARD (GCs: oral, IV and IM, prednisolone/prednisone cumulative dose range: 630mg to 7500mg; GC treatment duration: 12-34 weeks; DMARDs: MTX, MTX+HCQ, MTX+Ci, MTX+LEF, Aurothioglucose, sodium aurothiomalate, SSZ, Gold, Gold+penicillamine+azathioprine)
Comparator
Placebo GC + (same) DMARD
Outcomes

PICO 3.1

Population
Adults with psoriatic arthritis
Intervention
Opioids
Comparator
Analgesics
Outcomes

PICO 3.2

Population
Axial spondyloarthritis patients with low disease activity
Intervention
Discontinuation
Comparator
Continuation
Outcomes

PICO 3.2

Population
Adults with rheumatoid arthritis initiating/adding/switching DMARD therapy (Comparison 2)
Intervention
Bridging GC + DMARD
Comparator
(same) DMARD alone
Outcomes

PICO 3.3

Population
Axial spondyloarthritis patients with low disease activity - DUPLICATE DURING UPDATE (July 2023)
Intervention
Dose reduction
Comparator
Continuation
Outcomes

PICO 3.3

Population
Adults with rheumatoid arthritis initiating/adding/switching DMARD therapy (Comparison 3)
Intervention
Bridging GC + DMARD + baseline GC (bridging GC: approx. 1000mg, IV MP for 24-52 weeks; induction DMARDs: MTX, SSZ; baseline GC: 5-10 mg oral prednisolone per day)
Comparator
(same) DMARD + baseline GC (5-10 mg oral prednisolone per day)
Outcomes

PICO 3.4

Population
Axial spondyloarthritis patients with low disease activity - DUPLICATE DURING UPDATE (July 2023)
Intervention
Discontinuation
Comparator
Continuation
Outcomes

PICO 3.4

Population
Adults with rheumatoid arthritis initiating/adding/switching DMARD therapy (Comparison 4)
Intervention
Parenteral bridging GC + DMARD
Comparator
Oral bridging GC + (same) DMARD
Outcomes

PICO 4.1

Population
Psoriatic arthritis patients with low disease activity
Intervention
Dose reduction
Comparator
Continuation
Outcomes

PICO 4.2

Population
Psoriatic arthritis patients with low disease activity
Intervention
Discontinuation
Comparator
Continuation
Outcomes

PICO 5.1

Population
Adults with rheumatoid arthritis
Intervention
Subcutaneous (SC) or Intramuscular (IM) Methotrexate (MTX)
Comparator
Oral Methotrexate (MTX) single dose: MTX 15 mg or 22.5 mg in a single dose weekly
Outcomes

PICO 5.2

Population
Adults with rheumatoid arthritis
Intervention
Subcutaneous (SC) or Intramuscular (IM) Methotrexate (MTX)
Comparator
Oral Methotrextate (MTX) split dose: MTX in divided doses: 7.5 mg twice a week or 7.5 mg thrice a week at 2–3 days’ interval
Outcomes

PICO 8.1

Population
Adults with inflammatory arthritis receiving DMARD therapy prior to elective surgery
Intervention
Perioperative discontinuation of csDMARDs
Comparator
Continuation of csDMARDs
Outcomes

PICO 8.2

Population
Adults with inflammatory arthritis receiving DMARD therapy prior to elective surgery (DUPLICATE DURING UPDATE)
Intervention
Perioperative discontinuation of csDMARDs
Comparator
Continuation of csDMARDs
Outcomes

PICO 9.1

Population
Adults with inflammatory arthritis
Intervention
Perioperative glucocorticoid stress dose
Comparator
Glucocorticoids at normal daily dose
Outcomes