ACR Guidelines for Integrative Approaches to Treatment of Rheumatoid Arthritis

The American College of Rheumatology (ACR) has issued new guidelines for an integrative approach to the treatment and management of patients with rheumatoid arthritis (RA), to be used as a complement to their previously published guidelines on pharmacologic therapies. The current guidelines prioritize exercise, rehabilitation, diet, and other integrative interventions for treating RA. The full report has been published in Arthritis & Rheumatology.

According to study authors, this is the first ACR guideline released on the use of exercise, rehabilitation, diet, and other integrative interventions in conjunction with disease-modifying antirheumatic drugs (DMARDS) for the management of RA.

To create clinical questions, authors utilized the Population, Intervention, Comparison, and Outcomes format. The main critical outcomes of these questions were physical function and pain, with disease activity and work outcomes considered additionally.

A team of experts from various fields conducted a systematic review to evaluate the literature for the most effective evidence-based practices for managing patients with RA. They then created an evidence report, which was later reviewed by a panel of 12 patients with RA who had varying experiences with the considered interventions. The patient panel provided their perspectives and preferences to the voting panel, who made recommendations based on the direction and strength of all included findings.

To evaluate the accuracy of the literature, experts used the Grading of Recommendations Assessment, Development and Evaluation methodology.

The voting panel agreed upon 28 recommendations for the use of integrative interventions alongside DMARDS to manage RA.

Of the 28 recommendations included within the guidelines, only 1 was deemed strong while the remaining 27 were conditional. Among the conditional recommendations, 4 focused on exercise, 13 pertained to rehabilitation, 3 were related to diet, and 7 suggested additional integrative interventions.

These ACR guidelines only pertain to RA and do not take into account its effects on other medical conditions or overall health. They are designed to be used alongside the recommended pharmacological treatment guidelines.

Exercise-Based Recommendations

The ACR strongly recommended consistent engagement in exercise. No specific guidelines for the type, frequency, intensity, and duration of exercise were outlined, except for emphasizing engagement in regular movement. The details of the exercise plan should be personalized to each patient based on their current health status, abilities, and access to resources.

Conditional recommendations were granted for the following exercise types: aerobic, aquatic, resistance-based, and mind-body-based (eg, yoga).

Rehabilitation-Based Recommendations

The ACR conditionally recommended participation in comprehensive programs of occupational therapy and physical therapy for managing RA related pain and improving physical functionality over no prespecified rehabilitation plan.

These programs include, but are not limited to, the following interventions: joint protection techniques, energy conservation, fatigue management, activity pacing and modification, adaptive equipment, assistive devices, hand therapy exercises, vocational rehabilitation, splinting, orthoses, compression, bracing, and/or taping.

Dietary Recommendations

The ACR conditionally recommended following a Mediterranean-style diet over not following a defined diet.

A Mediterranean-style diet emphasizes whole foods, including: low-fat dairy, fish, whole grains, vegetables, fruits, nuts/seeds, and olive oil. The Mediterranean-style diet includes limited intake of processed foods, added sugars, saturated fats, and refined carbohydrates.

Additionally, the ACR conditionally recommended againstfollowing any other formally defined diets and conditionally recommended adherence to already established dietary recommendations, without use or over-addition of dietary supplements.

Additional Recommendations

The following additional integrative interventions for RA were seen to have low certainty of evidence, but were associated with few harms, and were not considered too burdensome for most patients with RA:

The ACR conditionally recommended use of:

• ·       A standardized self-management program
• ·       Cognitive behavioral therapy and/or mind-body approaches
• ·       Massage therapy
• ·       Acupuncture
• ·       Thermal modalities

The ACR conditionally recommended against use of:

• ·       Chiropractic therapy
• ·       Electrotherapy

The authors of the guidelines concluded, “These recommendations complement existing pharmacological 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.”