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American College of Rheumatology issues recommendations on prescribing drugs for rheumatoid arthritis

Individuals who are diagnosed with rheumatoid arthritis are often prescribed drugs that suppress the immune system and slow the progression of joint damage that the disease causes. Called disease-modifying antirheumatic drugs (DMARDs), they can be taken by mouth or injection. Oral medications can be combined with one another or with injected DMARDs. Biologic DMARDs are a subset of the DMARDs; they are specialized proteins that suppress the immune system in a more targeted manner.

Because biologic DMARDs are increasingly being used, the American College of Rheumatology (ACR) updated its previous recommendations for the use of DMARDs, last issued in 2002. Researchers first completed a systematic literature review of scientific evidence. Following the five areas prespecified by the ACR, they examined indications for use, monitoring for side effects, assessing the clinical response, the roles of cost and patient preferences in decisionmaking, and the need for tuberculosis (TB) screening with use of biologic DMARDs.

Using this information, a core expert panel developed recommendations that a task force panel then critiqued and rated. They examined indications for starting or resuming five oral DMARDs (hydroxychloroquine, leflunomide, methotrexate, minocycline, and sulfasalazine) and five biologic DMARDs (abatacept, adalimumab, etanercept, infliximab, and rituximab). Drug contraindications-including infectious diseases, pregnancy, surgery, cardiac, hematologic, cancer, liver, renal, and neurologic adverse events-were also examined.

Recommendations included obtaining a baseline blood count, liver transaminase levels, and serum creatinine levels for any patient receiving DMARDs. Immunizations for influenza and pneumococcal vaccinations were recommended before starting most of these drugs. Patients about to embark on biologic DMARDs should also be screened for latent TB infection because of a higher incidence of TB following therapy with certain DMARDs.

This study was funded in part by a grant to the University of Alabama Center for Education and Research on Therapeutics (CERT) from the Agency for Healthcare Research and Quality (HS10389).

For more information on the CERTs program, please visit http://www.ahrq.gov

See "American College of Rheumatology 2008 recommendations for the use of nonbiologic and biologic disease-modifying antirheumatic drugs in rheumatoid arthritis," by Kenneth G. Saag, M.D., M.Sc., Gim Gee Teng, M.D., Nivedita M. Patkar, M.D., M.S.P.H., and others in the June 15, 2008, Arthritis & Rheumatism (Arthritis Care & Research) 59(6), pp. 762-784.

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