Australian living guidelines: tapering DMARDs

2 minute read

Dr Sam Whittle talks about his work on living guidelines for rheumatoid arthritis, psoriatic arthritis and axial spondyloarthritis.

Living guidelines could soon be the gold standard for treating inflammatory diseases. Here’s how they work.

Recently on the Rheumatology Republic podcast, Dr Sam Whittle joined us to explain some of the work he’s been doing on living guidelines for rheumatoid arthritis, psoriatic arthritis and axial spondyloarthritis.

The most well-known example of living guidelines – that is, where recommendations are updated as new literature emerges – has been the Australian COVID-19 guidelines.

Dr Whittle said the COVID-19 example has been a good demonstration case of how the process works and demonstrates the value of living guidelines when there is a rapidly changing literature base.

The process of creating living guidelines starts with what is essentially a systematic review of existing evidence, which is then presented to a panel of experts who make an evidence-based recommendation.

“We present all of the evidence we have in a framework for making the decision, which is written out explicitly,” Dr Whittle said.

“We also have a rationale that we publish, and a series of practical information points.”

Inflammatory arthritis makes a particularly fertile topic for living recommendations, according to Dr Whittle, due to continued research and an expanding literature base.

“Over the last 20 years, we’ve seen the advent of biological and targeted synthetic DMARDs, we’ve seen a huge expansion in the number of pharmacological options available for the treatment of inflammatory diseases,” he said.

“That means that it’s really the perfect theatre for a living guideline.”

One of the benefits of living guidelines, according to Dr Whittle, is that recommendations can be developed one at a time, allowing for prioritisation of certain aspects.

With this in mind, Dr Whittle and his team surveyed members of the Australian Rheumatology Association, asking them to nominate and rank topics which they felt needed to be addressed in national guidelines.

“One of the ones that came out very near the top was how to taper DMARDs, particularly biological and targeted synthetic DMARDs, so that was the topic that we decided to go with first,” he told RR.

All recommendations which have been made as part of the living guidelines – including one related to the COVID-19 vaccine – are currently listed as ‘conditional’. Dr Whittle anticipates NHMRC endorsement for the guidelines within the year.

The guidelines are available at point-of-care via a web app, along with information on how up-to-date each recommendation is and direct links to relevant literature.

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