Each year at its annual meeting, the American College of Rheumatology (ACR) introduces new or updated evidenced-based clinical practice recommendations that reflect recent clinical trial results and/or incorporate newly approved treatments. These recommendations advise clinicians of important new data that can improve the quality, appropriateness, and cost-effectiveness of patient care. At this year's meeting, Jasvinder Singh, MD, MBBS, University of Alabama, Birmingham, Alabama, USA, presented updated recommendations for the use of nonbiologic and biologic disease-modifying antirheumatic drugs (DMARDS) for rheumatoid arthritis (RA). Bevra H. Hahn, MD, UCLA School of Medicine, Los Angeles, California, USA, presented new guidelines for the management of lupus nephritis.

Both sets of recommendations were developed using the RAND/UCLA Appropriateness Method, a formal group judgment method that contains elements of the Delphi technique and Nominal Group Process that uses clinically detailed ‘scenarios’ of diagnosis or treatment. Applying this method, the working group and core expert panel applied the results of a systematic review of the literature to create evidence reports and clinical scenarios, which were reviewed, rated, analyzed, and graded by members of the task force and eventually submitted to the ACR for finalization.

Updated Guidelines for Patients with Rheumatoid Arthritis

Among the important changes in the 2012 Updated Recommendations for the Treatment of RA are recommendations for the use of three newly approved drugs (tocilizumab, golimumab, and certolizumab), updated recommendations for switching therapies, indications for starting or resuming biologic or nonbiologic DMARDs, contraindications to the use of these agents, safety, and preventive immunizations. A key characteristic of these guidelines is that only “positive” recommendations are included, meaning that there are no statements on when NOT to start a therapy, based on efficacy considerations, and no statements when it is “permissible” to use an agent on the basis of safety considerations.

The ACR 2012 Task Force panel recommends that in both early RA (defined as disease duration <6 months) and established RA (defined as disease duration ≥6 months or meeting 1987 ACR classification criteria), the target for disease activity should be either remission (Disease Activity Score [DAS] <1.6) or low disease activity (DAS <2.4).

Updated Guidelines for Patients with Lupus Nephritis

The new Guidelines for the Management of Lupus Nephritis contain recommendations for screening, treatment, and patient management. Since treatment is dependent on biopsy results, the guidelines include treatment algorithms and recommendations for inducing improvements in various histological types of lupus nephritis, with a section on how to maintain improvements in patients who respond.

The panel has assigned a Level of Evidence (LOE), based on the strength of the supporting data, to each recommendation. A: Evidence derived from multiple randomized controlled trials (RCTs) or a meta-analysis; B: Evidence based on a single RCT or nonrandomized study; C: Recommendation based on consensus, expert opinion, or case series.

Renal Biopsy (All LOE: C)

• Every patient with clinical evidence of active lupus nephritis, previously untreated, should undergo renal biopsy unless strongly contraindicated

• Biopsy results should be classified by the current International Society of Nephrology/Renal Pathology Society classification [www.theisn.org]

• The recommended therapeutic strategies are based on knowing the classification of nephritis on renal biopsy

All patients with lupus nephritis should receive the following adjunctive therapies:

• Hydroxychloroquine (LOE: C)

• Angiotensin-converting enzyme inhibitor or angiotensin receptor blocker for proteinuria ≥0.5 g/24 hrs or equivalent protein/creatinine ratio (LOE: A)

• Maintain blood pressure ≤130/80 mm Hg (LOE: A)

• Statins for low-density lipoprotein cholesterol level (LDL) >100 mg/dL (LOE: C)

• Pregnancy counseling for fertile women (LOE: C)

Treatment algorithms have been developed for patients with ISN/RPS Class III/IV proliferative disease with and without crescents, which include recommendations for induction therapy, maintenance therapy for responders, and treatment approaches for nonresponders. For patients with Class V, purely membranous disease with nephrotic-range proteinuria (≥3 g/24 hours), the recommendation is to begin with mycophenolate mofetil (MMF) 2 to 3 g+prednisone 0.5 mg/kg daily for 6 months. Patients who improve can be moved to a maintenance regimen of MMF 1 to 2 g/day or azothioprine 2 mg/kg/day. Patients who do not improve should be treated with cyclophosphamide 500 to 1000 mg/twice per month for 6 months + a steroid pulse that is followed by daily prednisone (0.5 to 1.0 mg/kg/day). New recommendations have also been issued for lupus nephritis in pregnancy.

Monthly monitoring is recommended for all patients with lupus nephritis (Table 2).

Despite progress, a significant unmet need remains for patients with lupus nephritis. Approximately 20% to 35% of patients do not respond to treatment, and for many patients, response is slow (8 to 52 weeks). In addition, many responders can not completely discontinue therapies.

Dr. Hahn noted that the recent approval of belimumab for adult patients with active, autoantibody-positive systemic lupus erythematosus (SLE) has led to a number of inquiries from SLE patients with lupus nephritis. She stressed that belimumab has not been studied in SLE patients with active nephritis. Although a post hoc analysis [Petri MA. Lancet 2011] of the published trial [Navarra SV et al. Lancet 2011] showed a significant (p<0.03) reduction in renal flares in the belimumab group, this was in patients with a history of nephritis, not currently active nephritis.