RA is a chronic, lifelong, progressive condition. For this reason, patients and clinicians constantly strive to maximize treatment for the inflammatory disease, which may include integrative approaches, says a co-principal investigator of the guidelines, Benjamin J. Smith, a doctor of medical science and the interim program director and associate dean at the school of physician assistant practice at Florida State University College of Medicine in Tallahassee.
First-Ever Guideline Builds on ACR Medication Recommendations
“This guideline, the first of its kind developed by the ACR, provides guidance for patients and clinicians when considering many integrative treatment options,” says Dr. Smith. These new recommendations are considered complementary to the ACR’s 2021 Guideline for the Treatment of RA, which covers pharmacological therapies, he adds.
It’s the Right Time to Talk About CAM
Patient outcomes have come a long way in RA over the past few decades, says the co-principal investigator Bryant R. England, MD, PhD, an associate professor in the division of rheumatology and immunology at the University of Nebraska Medical Center in Omaha. Successful disease management means more people want to expand options. “In addition to early diagnosis, better treatment strategies and pharmacologic treatment options have been crucial to this success. Both patients and clinicians have been engaging in more discussions about CAM [complementary and alternative medicine] interventions to improve their outcomes that work alongside the medications they are taking,” says Dr. England. “Over the past 5 to 10 years, the focus has been on medication, and the fact that they are now highlighting the importance of these adjunct treatment modalities is a huge step forward for patients with RA,” says Dennis Ang, MD, a researcher and professor of rheumatology and immunology at Wake Forest University School of Medicine in Winston-Salem, North Carolina. Dr. Ang was not involved in writing the new guidelines. In Ang’s practice, about half of people with RA are looking for additional therapeutic approaches to help them deal with their pain, disability, and function. “Not everyone is interested or open to therapies beyond medications, but a substantial portion are interested in adopting these types of recommendations, he says.
Panel Included People With RA as Well as Medical Experts
The 20-person panel that decided on the guidelines and the strength of recommendations included experts in epidemiology, exercise physiology, integrative medicine, nursing, nutrition, occupational therapy, physical therapy, rheumatology, social work, and three people with RA.
Treatment Standards Remain; DMARDs Are Essential
First and foremost, RA should be treated with disease-modifying antirheumatic drugs (DMARDs) according to pharmacological treatment guidelines. “We’ve made huge strides in RA outcomes because of this, so we need to continue to treat to target with DMARDs,” says England. Second, the recommendations in this guideline are specific to RA management, he notes. Many of the interventions may not have evidence that they help with RA, but may be beneficial for other conditions, says England. The guideline includes 28 recommendations, with “moving regularly” being the only strong recommendation. Out of the 27 conditional recommendations, 4 were about exercise, 13 about rehabilitation, 3 about diet, and 7 about additional integrative interventions. A conditional recommendation is one for which the benefits probably outweigh any downsides, but it’s not completely certain given the current evidence. In some cases, there haven’t been enough well-designed studies to show the impact of the intervention on RA. Massage therapy, splinting, physical therapy, and occupational therapy were all conditionally recommended by the panel.
The Only Strong Recommendation: Move Regularly
The panel members and the evidence aligned with a strong recommendation supporting regular exercise, meaning “moving regularly,” says England. “This can be thought of as a strategy or principle which will then need to be applied and tailored to each patient,” he says. Exercise preferences are personal, and activities should be enjoyable. Patients and clinicians should integrate discussions of their physical activity levels into their regular visits, and through shared decision-making they can identify the types of exercise, frequency, duration, and intensity that are appropriate, says England. “Referrals to physical therapists or clinical exercise physiologists can help patients safely make moving regularly part of their lifestyle,” he says. Ang first considers a patient’s physical activity history before making a recommendation on exercise. “For example, if in the past they have been very sedentary and now want to start exercising, I would suggest they start with 5 to 10 minutes of brisk walking,” he says. For those with more time and resources, enrolling in a community fitness facility such as the YMCA to do group exercise is another great option, says Ang. “When appropriate, I encourage my patients with rheumatoid arthritis to consider gentle yoga or tai chi (if they don’t have balance issues) as part of a daily routine,” he says.
Conditional Recommendations for a Mediterranean-Style Diet
Adherence to a Mediterranean diet was conditionally recommended over no formally defined diet, says England. “The evidence suggested improvement in pain when following a Mediterranean-style diet, but the level of evidence was not supportive of a strong recommendation,” he says. A Mediterranean-style diet emphasizes vegetables, fruits, whole grains, nuts, seeds, and olive oil; moderate amounts of low-fat dairy and fish; and limits added sugars, highly processed foods, and saturated fats. What’s more, the diet appears to lower the risk of cardiovascular disease, as shown by studies in the general population, says England. “This is important in RA, where patients have an increased risk of CVD-events and CVD-related mortality,” he says.
People With RA Still Need Support to Stop Smoking, Maintain a Healthy Weight
The guideline authors recommend that rheumatologists encourage their patients to stop smoking and maintain a healthy weight. All clinicians have a general role in counseling and helping patients find interventions that work for them, according to Sunday’s presentation. To this end, Ang typically recommends daily caloric restriction to his RA patients who have overweight or obesity rather than one specific type of diet. Pharmacological and surgical options can be considered as well, the authors stated.
Teamwork Is Best for Holistic Success
The guideline highlights the interprofessional team of experts contributing to the care of persons with RA, says Smith. “Optimal patient outcomes can be achieved through interprofessional teams,” he says. For example, a physical therapist or massage therapist might be included in the team.
Shared Decision Making on Integrative Interventions Is Key
Since most of the recommendations were conditional, a discussion and shared decision-making is important, according to the authors. The lack of evidence to strongly recommend most complementary and alternative medicine therapies also highlights the need for additional research, they said.
Striving for Minimally Disruptive Medicine
The burden of a disease such as RA is high, and the committee recommends that doctors use a patient-centered model that focuses on helping patients achieve their goals for life and health with treatments and practical interventions that impose “the smallest possible treatment burden on their patients’ lives.” This is especially true for people with RA who are at risk of being (or already are) overwhelmed by the challenges of life, illness, and healthcare.
