CME

 

Introduction to the South African Rheumatism and Arthritis Association 2024 guidelines

 

 

B Hodkinson^I; E van Duuren^II; A Maharaj^III; F Paruk^IV; K Makan^V

^IMB BCh, PhD; Rheumatology Division, Department of Medicine, Groote Schuur Hospital and Faculty of Health Sciences, University of Cape Town, South Africa
^IIMB ChB, MMed (Int Med); Jacaranda Hospital, Pretoria, South Africa
^IIIMB BS, PhD; Department of Internal Medicine and Pharmacology, Faculty of Health Sciences, Walter Sisulu University, Mthatha, South Africa
^IVMB BCh, PhD; Division of Internal Medicine, School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa; Ahmed Al-Kadi Private Hospital, Durban, South Africa
^VMB ChB; Department of Medicine, Chris Hani Baragwanath Academic Hospital and Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa

Correspondence

 

 

---

ABSTRACT

The guidelines in this series provide evidence-based practical guidance for the diagnosis, treatment and follow-up of persons with inflammatory joint diseases. The purpose of these guidelines is to aid in shared decision-making between patient and physician, aiming to support high-quality clinical care. These guidelines have been prepared using the AGREE II instrument and based on adoption and, where appropriate, adaptation of international guidelines.

Keywords: Rheumatism, arthitis, guidelines

---

 

 

The guidelines in this series provide evidence-based practical guidance for the diagnosis, treatment and follow-up of persons with inflammatory joint diseases. They include an update of the 2013 recommendations for the management of rheumatoid arthritis (RA)^[1] and guidelines for the use of biologic and targeted synthetic drug (b/tsDMARD) therapies (September 2024 SAMJ), and new guidelines for the management of spondyolarthritis (SpA) (October 2024). These guidelines have been prepared using the AGREE II instrument.^[2]

 

Objectives and scope of guidelines

The strategies outlined in these guidelines provide a clear evidence-based approach to the diagnosis and management of the common inflammatory joint diseases. The target population of the guidelines is adults (>18 years) with RA, axial SpA (axSpA) and peripheral SpA, with other autoimmune inflammatory conditions (systemic lupus erythematosus, systemic sclerosis, inflammatory myositis, vasculitis and Behcet's disease) mentioned only briefly in relation to the use of biologic therapies. These recommendations offer guidelines for the management (including screening, diagnosis, investigation and treatment) of these conditions in South Africa (SA). The outcomes of importance include control of disease activity (aiming for low disease activity, or ideally remission), prevention of irreversible structural damage, preservation of health-related quality of life, and management of complications and comorbidities. The purpose of these guidelines is to enhance the practice of the physician and aid in shared decision-making between patient and physician.

The health questions covered by these guidelines pertaining to RA and peripheral and axSpA, and relevant to the prescription of b/ tsDMARDs, include:

• What are the appropriate screening and diagnostic tools for these diseases?

• How are disease activity and functional disability assessed?

• What are the principles of management, including treatment goals, lifestyle interventions, and management of comorbidities?

• What are the details of therapies, including recommendations to guide choice and sequence of medication, particulars of eligibility and registry requirements, and adverse effects?

 

Target users

These guidelines are intended for rheumatologists, physicians, primary healthcare clinicians, allied healthcare professionals, patients, patient organisations, regulatory agencies and reimbursement institutions, policymakers, health insurance companies and the pharmaceutical industry. The aim is to support high-quality clinical care. All recommendations should be applied with clinical judgement, and decisions about care for each individual patient will rest with the individual clinician and patient.

 

Need for guidelines in SA

Most international recommendations and guidelines are based on evidence from studies done predominantly in Europe and North America. These guidelines may not be relevant or applicable to the SA population. The increasing prevalence of tuberculosis (TB), HIV, hepatitis B, and other infections in sub-Saharan Africa, together with resource constraints and the small number of rheumatologists, suggest that country-specific guidelines are needed.

There are limited published data from SA to inform local recommendations, so the steering committees have based these guidelines on data already published, tailored to our region, expert opinion and consensus, so that patients can obtain maximum benefit with the limited resources available.

 

Methods

The South African Rheumatism and Arthritis Association (SARAA) gave the mandate to produce new or updated guidelines at the Biennial General Meeting in 2017 (Fig. 1). A task force was appointed, and a systematic literature search (MEDLINE) was conducted to identify guidelines from other global organisations published in English during the past 6 years (January 2017 - June 2023), in addition to relevant randomised controlled trials or opinion papers relevant to the SA context. Search termr Included: rheumatoid arthritis; axial spondyloarthritis; psoriatic arthritis; reactive arthritis; inflammatory bowel disease-associated arthritis; and biologic and targeted synthetic disease-modifying antirheumatic drugs. Recommendations or guidelines from the following organisations were specifically included: European Alliance of Associations for Rheumatology (formerly the European League Against Rheumatism); American College of Rheumatology; Group for Research and Assessment of Psoriasis and Psoriatic Arthritis; and Assessment of SpondyloArthritis International Society. ^[3-19] AGREE II appraisal of these guidelines was performed, and they were assessed as good quality (Appendix 1, available online at https://www.samedical.org/file/2274). These SARAA guidelines are therefore based on adoption and, where appropriate, adaptation of international guidelines.

 

 

The task force summarised and tabulated the literature and identified three important features in SA that needed consideration when formulating local guidelines: the high prevalence of endemic infections (particularly TB, HIV and hepatitis B); poor socioeconomic status of the majority of South Africans; and lack of availability of certain therapies.

Based on this review, provisional guidelines were presented at a dedicated meeting (July 2018) open to all SARAA members. The health benefits, side-effects and risks of each intervention were carefully considered, based on available evidence and also on the collective experience of practising SA rheumatologists. After each presentation, discussion resolved all queries or controversies, and final decisions on guidelines were made. There were no issues that required a formal vote to resolve. Final drafts of the guidelines were prepared.

A five-member steering committee for each set of guidelines was appointed by SARAA to perform an external review. Each steering committee consisted of an academic rheumatologist, a rheumatologist working in the private sector, a member of the SARAA young rheumatology forum (a fellow or recently qualified rheumatologist), and a patient representative. The final drafts of each recommendation were reviewed, updated and corrected by the relevant steering committee.

Funding. These guidelines were developed with external funding from the following pharmaceutical companies (in alphabetical order): AbbVie, Amgen, Eli Lilly, Janssen and Novartis. Contributions towards the costs of the July 2018 meeting to finalise the guidelines were made by the following pharmaceutical companies (in alphabetical order): AbbVie, Adcock, Cipla, Janssen, Pfizer, Roche, Mundipharma and Novartis. Funders did not participate in the task forces or steering committees, or in the guideline meeting. The views or interests of the funders have not influenced the final guidelines.

Dissemination of these guidelines. It is anticipated that each recommendation, together with the tables and figures prepared for easy reference, will be widely disseminated and implemented.

Updates. The intention is to update these guidelines every 5 years, or when new therapies and new evidence become available. The same methodology adopted for the present guidelines will be used for future guidelines.

Limitations of these guidelines. The guideline development group included clinicians and researchers but did not include methodologists or systematic review experts, and funder or policymaker engagement did not take place.

Guideline panel member list. Appendix 2 (available online at https://www.samedical.org/file/2273) lists the panel members and their institutional details.

Declaration. A Maharaj has received honoraria/ consultancy fees from AbbVie, Pfizer, Janssen, Roche and AstraZeneca and has also received speaker fees from AbbVie, Pfizer, Janssen and Novartis. R Benitha has received honoraria/consultancy fees from Abbvie, Pfizer, Janssen, Roche, Eli-lilly, Adcock-Ingram and Novartis.

 

References

1. Hodkinson B, van Duuren E, Pettipher C, Kalla A; South African Rheumatism and Arthritis Association. South African recommendations for the management of rheumatoid arthritis: An algorithm for the standard of care in 2013. S Afr Med J 2013;103(8):576-585. https://doi.org/10.7196/SAMJ.7047        [ Links ]

2. AGREE Next Steps Consortium (2017). The AGREE II Instrument (Electronic version). http://www.agreetrust.org (accessed 22 May 2018).         [ Links ]

3. Smolen JS, Landewé RB, Bijlsma JW, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2019 update. Ann Rheum Dis 2020;79(6):685-699. https://doi.org/10.1136/annrheumdis-2019-216655        [ Links ]

4. Smolen JS, Landewé R, Bijlsma J, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2016 update. Ann Rheum Dis 2017;76(6):960-977. https://doi.org/10.1136/annrheumdis-2016-210715        [ Links ]

5. Bech B, Primdahl J, van Tubergen A, et al. 2018 update of the EULAR recommendations for the role of the nurse in the management of chronic inflammatory arthritis. Ann Rheum Dis 2020;79(1):61-68. https://doi.org/10.1136/anniheumdis-2019-215458        [ Links ]

6. Gossec L, Baraliakos X, Kerschbaumer A, et al. EULAR recommendations for the management of psoriatic arthritis with pharmacological therapies: 2019 update. Ann Rheum Dis 2020;79(6):700-712. https://doi.org/10.1136/annrheumdis-2020-217159        [ Links ]

7. Coates L, Gossec L. The updated GRAPPA and EULAR recommendations for the management of psoriatic arthritis: Similarities and difierences. Joint Bone Spine 2023;90(1):105469. https://doi.org/10.1016/j.jbspin.2022.105469        [ Links ]

8. Ramiro S, Nikiphorou E, Sepriano A, et al. ASAS-EULAR recommendations for the management of axial spondyloarthritis: 2022 update. Ann Rheum Dis 2023;82(1):19-34. https://doi.org/10.1136/ard-2022-223296        [ Links ]

9. Van der Heijde D, Ramiro S, Landewé R, et al. 2016 update of the ASAS-EULAR management recommendations for axial spondyloarthritis. Ann Rheum Dis 2017;76(6):978-991. https://doi.org/10.1136/annrheumdis-2016-210770        [ Links ]

10. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res (Hoboken) 2021;73(7):924-939. https://doi.org/10.1002/acr.24596        [ Links ]

11. Singh JA, Saag KG, Bridges SL Jr, et al. 2015 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res (Hoboken) 2016;68(1):1-26. https://doi.org/10.1002/acr.22783        [ Links ]

12. Coates LC, Soriano ER, Corp N, et al. Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA): Updated treatment recommendations for psoriatic arthritis 2021. Nature Rev Rheumatol 2022;18(8):465-479. https://doi.org/10.1038/s41584-022-00798-0        [ Links ]

13. Coates LC, FitzGerald O, Merola JF, et al. Group for Research and Assessment of Psoriasis and Psoriatic Arthritis/Outcome Measures in Rheumatology consensus-based recommendations and research agenda for use of composite measures and treatment targets in psoriatic arthritis. Arthritis Rheumatol 2018;70(3):345-355. https://doi.org/10.1002/art.40391        [ Links ]

14. Smolen JS, Landewé RB, Bergstra SA, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biologic disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis 2023;82(1):3-18.         [ Links ]

15. Gossec L, Kerschbaumer A, Ferreira RJO, et al. EULAR recommendations for the management of psoriatic arthritis with pharmacological therapies: 2023 update. Ann Rheum Dis 2024;83(6):706-719. https://doi.org/10.1136/ard-2024-225531        [ Links ]

16. Ward MM, Deodhar A, Gensler LS, et al. 2019 update of the American College of Rheumatology/ Spondylitis Association of America/Spondyloarthritis Research and Treatment Network recommendations for the treatment of ankylosing spondylitis and nonradiographic axial spondyloarthritis. Arthritis Care Res (Hoboken) 2019;71(10):1599-1613. https://doi.org/10.1002/acr.24025        [ Links ]

17. Hamilton L, Barkham N, Bhalla A, et al. BSR and BHPR guideline for the treatment of axial spondyloarthritis (including ankylosing spondylitis) with biologics. Rheumatology (Oxford) 2017;56(2):313-316. https://doi.org/10.1093/rheumatology/kew223        [ Links ]

18. Tucker L, Allen A, Chandler D, et al. The 2022 British Society for Rheumatology guideline for the treatment of psoriatic arthritis with biologic and targeted synthetic DMARDs. Rheumatology (Oxford) 2022;61(9):e255-e266. https://doi.org/10.1093/rheumatology/keac295        [ Links ]

19. Singh JA, Guyatt G, Ogdie A, et al. 2018 American College of Rheumatology/National Psoriasis Foundation guideline for the treatment of psoriatic arthritis. J Psoriasis Psoriatic Arthritis 2019;4(1):31-58. https://doi.org/10.1177/2475530318812244        [ Links ]

 

 

Correspondence:
B Hodkinson
drbridget@gmail.com

Received 21 August 2023
Accepted 1 July 2024