The American College of Rheumatology (ACR) and Vasculitis Foundation have released a preview of the new practice guideline on the management of vasculitis at the 2019 ACR/Association of Rheumatology Professionals (ARP) Annual Meeting. The guideline will highlight the management of large-vessel, medium-vessel, and antineutrophil cytoplasmic antibodies (ANCA)-related conditions with recommendations on the use of glucocorticoids, diagnostic testing, surgical interventions, and more.

“The ACR and Vasculitis Foundation have banded together to help support the creation of this first set of guidelines,” Sharon Chung, MD, from the University of California, San Francisco, and lead investigator on the new practice guideline for vasculitis, said during a press conference at the meeting. “Our goal for these guidelines is to provide a blueprint and some reassurance for practitioners who may not be as experienced in caring for these diseases because they are so rare.”

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The full list of recommendations and supporting evidence are currently under review and are anticipated to be published by the spring of 2020.

To draft the guidelines, Dr Chung and colleagues developed relevant clinical questions and reviewed evidence supporting potential interventions for those questions.

The guideline highlighted by Chung includes the following recommendations based on conditional evidence:

• Glucocorticoid-sparing therapies are suggested as initial treatment of giant cell arteritis (GCA).
• To identify large-vessel involvement in newly diagnosed GCA, it is suggested that specialists use vascular imaging.
• To treat patients with granulomatosis with polyangiitis and microscopic polyangiitis, it is suggested to use a reduced-dose glucocorticoid dosing strategy.

According to Chung, some general themes across all the guidelines drafted include the following:

• Supporting the use of biologic medications as first-line therapies for certain diseases. “These agents are particularly exciting for our patients, since they have shown to decrease the need for prednisone,” Chung said.
• The appropriate use of laboratory testing. “We really emphasize that the whole patient should be examined; yes, you can do the laboratory testing, but you should also take a look at the patient and their symptoms and monitor the patient over time to really determine how active the disease is,” Chung said.
• A call for additional research and additional training.

Dr Chung noted that some of the new recommendations do contradict the recommendations of other organizations.

“There is an organization that recommends the use of temporal artery ultrasound over temporal artery biopsy for giant cell arteritis, but we are still recommending biopsy over ultrasound and it is not because ultrasound is a bad test, it is because most of the clinicians in this country have not been trained well to perform this test.”

The appropriate next steps are for clinicians to incorporate the guidelines into practice and change the way they practice as they see fit, according to Chung.

“An inappropriate next step [for clinicians to take] is to take these recommendations and restrict access to care to certain medications,” she said. “One option may be preferred, but there are patient factors that need to be considered, considering all recommendations are conditional.”

—Melinda Stevens

Reference:

American College of Rheumatology/Vasculitis Foundation preview new draft recommendations for vasculitis treatment at the 2019 ACR/ARP Annual Meeting [press release]. Atlanta, GA: 2019 ACR/ARP Annual Meeting; November 9, 2019. https://www.rheumatology.org/About-Us/Newsroom/Press-Releases/ID/1074. Accessed November 12, 2019.