ACR Guidelines Recommend an Integrated Approach to Managing Rheumatoid Arthritis

The American College of Rheumatology has released new recommendations for the use of diet, exercise, rehabilitation, and other interventions in conjunction with disease-modifying antirheumatic drugs (DMARDs) for the management of rheumatoid arthritis (RA). The guidelines were published simultaneously in Arthritis & Rheumatology and in Arthritis Care & Research.

Recommendations were created based on a systematic literature review and a voting panel made up of an interdisciplinary group, including 3 individuals with RA. The panel achieved consensus on 28 recommendations of varying strength.

A strong recommendation was made for consistent engagement in exercise in addition to treatment with DMARDs, based on evidence suggesting that regular exercise, compared with no exercise, results in improved function and reduced pain. Aerobic, resistance, aquatic, and mind-body exercise were considered together for this recommendation, but exercise type, frequency, intensity, and duration were not formally defined in these guidelines based on existing research. “The specific elements of an exercise intervention should be tailored to each person at the given time in their disease trajectory, considering their capabilities, access, and other health conditions,” the voting panel wrote.

Twenty-seven conditional recommendations were made, of which 4 pertained to exercise, 13 to rehabilitation, 3 to diet, and 7 to additional integrative interventions. The panel conditionally recommended participation in comprehensive occupational and physical therapy (over no such therapies) based on very low or low evidence. “Clinicians should discuss the opportunity to refer the patient to OT and/or PT early in the RA disease course, with the recognition that occupational therapy and/or physical therapy interventions can be tailored to unique patient needs throughout the patient’s experience with RA,” they wrote.

Regarding diet, the panel conditionally recommended adherence to a Mediterranean-style diet over no formally defined diet (based on low to moderate evidence). “The Mediterranean-style diet pattern emphasizes the intake of vegetables, fruits, whole grains, nuts, seeds, and olive oil and the intake of moderate amounts of low-fat dairy and fish, and limits the use of added sugars, sodium, highly processed foods, refined carbohydrates, and saturated fats,” panelists wrote. They also conditionally recommended against adherence to other formally defined diets other than Mediterranean-style.

The voting panel did not vote on recommendations regarding specific weight loss interventions for RA management in overweight or obese patients; however, they voted unanimously in support of clinicians discussing maintenance of a healthy body weight for all patients with RA. The panel also conditionally recommended against the use of electrotherapy and chiropractic therapy for the management of RA.

In summary, the voting panel wrote that “these recommendations complement existing pharmacologic treatment guidelines that instruct on the use of DMARDs and, taken together, can guide a shared decision-making approach between the individual with RA and their clinician.”