Journal of Rheumatic Diseases

Table. 2.

Expert opinion for the management of inflammatory arthritis in adults with biological disease-modifying antirheumatic drugs* in South Korea

Recommendation Appropriateness/Median Likert Scale score Level of agreement(%, agreement)
1.bDAMRDs should be prescribed by an expert experienced in the diagnosing and managing rheumatic diseases, who can monitor disease activity using standardized assessment tools, and perform safety monitoring (LOE: low, SOR: strongly recommended) A/9 High agreement (100)
2.Patients should be provided with education about their treatment with bDMARDs (LOE: moderate, SOR: strongly recommended) A/9 High agreement (100)
3.In RA, if the treatment target is not achieved with the first csDMARDs strategy, when poor prognostic factors§ are present, addition of a bDMARD should be considered (LOE: moderate, SOR: strongly recommended) A/9 High agreement (100)
4.In AS, bDMARDs should be considered in patients with persistently high disease activity despite conventional treatments including NSAIDs; current practice is to start with TNFi therapy (LOE: high for TNFi/Moderate for IL-17 inhibitor, SOR: strongly recommended) A/9 High agreement (100)
5.In RA, bDMARDs should be combined with a csDMARDs such as MTX (LOE: high, SOR: strongly recommended) A/9 High agreement (100)
6.In AS, bDMARD monotherapy without csDMARDs is recommended patients with purely axial disease (LOE: high, SOR: strongly recommended) A/9 High agreement (93.8)
7.In RA, if a bDMARD has failed, switching to another bDMARD should be considered (LOE: high, SOR: strongly recommended) A/9 High agreement (100)
8.In AS, if the treatment with the first TNF inhibitor has failed, switching to another TNF ihibitors or IL-17 in¬hibitor should be considered (LOE: low for TNF inhibitor/moderate for IL-17 inhibitor; SOR: weakly recommended for TNF inhibitors, strongly recommended for IL-17 inhibitor) A/9 High agreement (100)
9.Prior to initiating bDMARDs, disease activity, joint damage, functional capacity, extra-articular manifestations, comorbidities, vaccination history, and pregnancy status should be assessed in all patients with inflammatory arthritis (LOE: low, SOR: strongly recommended) A/9 High agreement (100)
10.All patients should be screened for active or latent tuberculosis before starting bDMARDs, and if tuberculosis is detected, patients should receive adequate anti-tuberculosis treatment, appropriately (LOE: low, SOR: strongly recommended) A/9 High agreement (100)
11.All patients should be screened for hepatitis B virus infection before starting bDMARDs, and if hepatitis B virus infection is identified, proper antiviral therapy should be considered (LOE: high for screening/low for antiviral therapy, SOR: strongly recommended) A/9 High agreement (100)
12.All patients receiving bDMARDs should be monitored for disease activity, joint damage, functional capacity, extra-articular manifestations, comorbidities, and drug side effects and toxicity (LOE: low, SOR: strongly recommended) A/9 High agreement (100)

bDMARDs: biologic disease modifying antirheumatic drugs, LOE: level of evidence, SOR: strength of recommendation, RA: rheumatoid arthritis, AS: ankylosing spondylitis, NSAIDs: non-steroidal anti-inflammatory drugs, TNFi: tumor necrosis factor inhibitor, MTX: methotrexate, csDMARDs: conventional synthetic disease modifying antirheumatic drugs, IL-17i: interleukin-17 inhibitor, A: appropriateness. *TNF-inhibitors (adalimumab, etanercept, golimumab, or infliximab), abatacept, rituximab, tocilizumab, or the respective European Medicines Agency (EMA)-approved/Food and Drug Administration (FDA)-approved biosimilars for the patients with RA; TNF-inhibitors (adalimumab, etanercept, golimumab, infliximab, or the respective EMA-approved/FDA-approved biosimilars) or IL-17 inhibitors for the patients with AS. Appropriateness was evaluated according to RAND/University of California Los Angeles (ULCA) appropriateness method; Appropriate (A) was defined as median score ranged 7∼9 without disagreement. Level of agreement was evaluated according to 9-point Likert scale; high agreement was defined as agreement scored between 7 and 9. §Positivity of rheumatoid factor or anti-citrullinated protein antibodies, joint damage, high disease activity, failure of ≥2 csDMARDs.

J Rheum Dis 2020;27:4~21 https://doi.org/10.4078/jrd.2020.27.1.4
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