Latest news with #treatmentGuidelines
Medscape
3 days ago
- Health
- Medscape
EULAR Updates Recommendations for Managing RA
BARCELONA, Spain — Patients with rheumatoid arthritis (RA) who have not responded to first-line methotrexate therapy should be started on a biologic or targeted synthetic disease-modifying antirheumatic drug (b/tsDMARD), according to new recommendations by the European Alliance of Associations for Rheumatology (EULAR). These updated recommendations contain five overarching principles and nine recommendations — two fewer than those in the 2022 iteration. Several of the recommendations remain unchanged, and a few were merged or modified to provide greater clarity. 'The availability of an increasing number of good drugs and increasing evidence due to wonderful clinical trials made the task force in charge of these recommendations produce increasingly leaner recommendations,' said Josef S. Smolen, MD, of the Medical University of Vienna, Vienna, Austria, who presented them at the EULAR 2025 Annual Meeting. 'It's nice because it makes life simpler.' Josef S. Smolen, MD EULAR continues to recommend methotrexate and short-term glucocorticoids as the first treatment strategy for RA. (In the case of contraindications, leflunomide or sulfasalazine should be considered.) 'We have yet to find something that beats methotrexate plus glucocorticoids [as a first therapy strategy],' Smolen said. However, if the treatment target is not reached with this first conventional synthetic (cs)DMARD approach, then the patient should be started on a b/tsDMARD. Second-Line Therapy With b/tsDMARDs This update eliminates treatment based on stratification according to poor prognostic factors, such as the presence of autoantibodies or high disease activity. In the 2022 recommendations, patients without these factors could start another csDMARD, whereas those with these poor prognostic factors could start a b/tsDMARD. 'The task force felt that the stratification was not necessary because if you fail methotrexate plus glucocorticoids, you already have a bad prognostic sign,' Smolen explained. Alexandre Sepriano, MD, PhD, an assistant professor of rheumatology at NOVA University Lisbon, Lisbon, Portugal, thought this change was the 'most important modification' to these RA treatment guidelines and would have 'significant implications for clinical practice.' He co-moderated the session where these updated recommendations were presented. Alexandre Sepriano, MD, PhD 'In some countries (eg, the United Kingdom), patients previously had to fail two csDMARDs before being eligible for a biologic or JAK inhibitor,' added Kim Lauper, MD, PhD, of Geneva University Hospitals, Geneva, Switzerland, the other moderator of the session. 'This new recommendation could help support policy changes that allow for earlier escalation, potentially helping more patients reach remission faster.' EULAR still recommends that b/tsDMARDs be combined with a csDMARD. In patients who cannot use a csDMARD as a co-medication, interleukin 6 inhibitors and JAK inhibitors 'may have some advantages compared with other bDMARDs,' the recommendations state. More Research Needed on JAK Inhibitors EULAR advises that clinicians should evaluate cardiovascular and malignancy risk factors before prescribing a JAK inhibitor. While the ORAL Surveillance trial found that the risk for major cardiovascular events and cancer was more common with tofacitinib than with TNF inhibitors, patient registries have not shown these same patterns, Smolen said. More randomized controlled trials are therefore needed to understand what could be driving the risk, he added. Kim Lauper, MD, PhD 'We're awaiting more data, and we would love to see and understand the mechanisms that led to a higher incidence of malignancies and cardiovascular events [in the ORAL Surveillance trial],' he said. Once a patient achieves sustained remission, they can taper to a lower DMARD dose; however, the new guidelines emphasize the importance of remaining on DMARDs and not stopping them entirely, Smolen said. 'Now, we more clearly state that this task force, based on newer data, felt that continuation of DMARDs — whether traditional [synthetic], biologic, or targeted synthetic DMARDs — is recommended, but dose reduction may be considered,' he continued.
Medscape
11-06-2025
- Health
- Medscape
CKD Therapy Unchanged by Patient and PCP Nudge Letters
VIENNA — Sending 'nudge' letters to patients with chronic kidney disease (CKD) or their general practitioners had no impact on their likelihood of receiving guideline-directed medical care, suggested a prescription analysis of over 22,000 Danish adults with CKD. METHODOLOGY: NUDGE-CKD included all Danish individuals aged 18 years or older on August 19, 2024, who had received a diagnosis of CKD in the previous 5 years during at least one hospital encounter and who were enrolled in the Danish governmental electronic letter system, which has 95% coverage. It also included all Danish general practices contactable via electronic letter that had at least one patient with CKD on their list. For patients, the letter highlighted the potential benefits of kidney and heart health and encouraged a discussion of treatment options, while for general practitioners, the letter focused on the latest treatment guidelines. In the patient arm of the study, 22,627 individuals were randomly assigned to receive a letter (n = 11,223) or no letter (n = 11,394). The average age was 71 years, and approximately 36% were women. For the practitioner arm, 1540 general practices, caring for 28,069 patients with CKD, were assigned to receive a letter (774 practices caring for 13,959 patients) or usual care (766 practices caring for 14,110 patients). The average patient age was 73 years, and approximately 39% were women. Both patients and practices were followed up for 6 months (until February 19, 2025), with the primary endpoint the number of filled prescriptions for a renin-angiotensin system inhibitor (RASi) or SGLT2 inhibitor (SGLT2i). TAKEAWAY: The patient analysis revealed that there was no significant difference in prescriptions of RASi or SGLT2i between those who received a nudge letter and those who did not, at a relative risk of 0.99 ( P = .21). = .21). Very similar results were seen on the general practice analysis, at a relative risk of a RASi or SGLT2i prescription with a nudge letter vs usual care of 0.99 ( P = .41). = .41). No significant differences were seen on the subgroup analysis and when looking at the time to prescription for new users, and there was no interaction between the patient and general practice results ( P = .85). IN PRACTICE: The trial was the 'largest provider-targeted implementation study to date evaluating a scalable, low-cost strategy to improve the use of guideline-related medical therapy in CKD' and the 'first large-scale trial of a digitally delivered strategy targeting patients with a common chronic condition,' said the study presenter. 'While the results were neutral, they may provide valuable insights for future efforts,' he concluded. SOURCE: The research was conducted by Kristoffer Grundtvig Skaarup, MD, Department of Cardiology, Copenhagen University Hospital — Herlev and Gentofte, Denmark, and colleagues, and described over two presentations at the 62nd European Renal Association (ERA) Congress 2025 on June 7. LIMITATIONS: Skaarup pointed out that, on the general practice side, the intervention was a 'one-time letter…and not linked to specific patients, which may have limited its lasting impact.' He suggested that more integrated approaches timed to clinical encounters or even embedded into existing clinical workflows closer to when prescription decisions are made may be more effective in primary care. Although most patients reported reading the letter, Skaarup said that few acted on it, potentially due to its general, non-personalized content, with no explicit medical therapy recommendations, which may limit its perceived relevance or urgency. DISCLOSURES: No external funding was obtained for the trial. Skaarup received funding through a research grant from the Danish Cardiovascular Academy, which is supported by the Novo Nordisk Foundation and the Danish Heart Foundation. No relevant financial relationships were declared. Liam Andrew Davenport, MA (Hons), is a UK-based medical journalist and writer with more than 20 years' experience. He studied medical sciences and anthropology at Emmanuel College, Cambridge, England.
