Recommendations for the treatment of rheumatoid arthritis in Saudi Arabia: adolopment of the 2021 American College of Rheumatology guidelines

Mohammed A Omair; Hanan Al Rayes; Joanne Khabsa; Sally Yaacoub; Sultana Abdulaziz; Ghada A Al Janobi; Abdulaziz Al Khalaf; Bader Al Mehmadi; Mahasin Al Nassar; Faisal AlBalawi; Abdullah S AlFurayj; Ahmed Hamdan Al-Jedai; Haya Mohammed Almalag; Hajer Yousef Almudaiheem; Ali AlRehaily; Mohammed A Attar; Lina El Kibbi; Hussein Halabi; Manal Hasan; Jasvinder A Singh; Liana Fraenkel; Elie A Akl

doi:10.1186/s41927-022-00301-y

Recommendations for the treatment of rheumatoid arthritis in Saudi Arabia: adolopment of the 2021 American College of Rheumatology guidelines

BMC Rheumatol. 2022 Nov 23;6(1):70. doi: 10.1186/s41927-022-00301-y.

Authors

Mohammed A Omair¹, Hanan Al Rayes², Joanne Khabsa^{3

4}, Sally Yaacoub^{3

4}, Sultana Abdulaziz⁵, Ghada A Al Janobi⁶, Abdulaziz Al Khalaf⁷, Bader Al Mehmadi⁸, Mahasin Al Nassar⁹, Faisal AlBalawi¹⁰, Abdullah S AlFurayj¹¹, Ahmed Hamdan Al-Jedai^{12

13}, Haya Mohammed Almalag¹⁴, Hajer Yousef Almudaiheem¹², Ali AlRehaily¹⁵, Mohammed A Attar¹⁶, Lina El Kibbi¹⁷, Hussein Halabi¹⁸, Manal Hasan¹⁹, Jasvinder A Singh^{20

21

22}, Liana Fraenkel^{23

24}, Elie A Akl^{25

26}

Affiliations

¹ Rheumatology Unit, Department of Medicine, King Saud University, PO Box 2925, Riyadh, 11461, Saudi Arabia. momair@ksu.edu.sa.
² Division of Rheumatology, Department of Internal Medicine, Prince Sultan Military Medical City, Riyadh, Saudi Arabia. alrayesh@hotmail.com.
³ AUB Grade Center, American University of Beirut Medical Center, Beirut, Lebanon.
⁴ Clinical Research Institute, American University of Beirut Medical Center, Beirut, Lebanon.
⁵ Division of Rheumatology, Department of Medicine, King Fahad Hospital, Jeddah, Saudi Arabia.
⁶ Rheumatology Unit, Department of Medicine, Qatif Central Hospital, Qatif, Saudi Arabia.
⁷ Rheumatology Unit, Department of Medicine, King Saud University, PO Box 2925, Riyadh, 11461, Saudi Arabia.
⁸ Division of Rheumatology, Department of Medicine, College of Medicine, Majmaah University, Al-Majmaah, 11952, Saudi Arabia.
⁹ Department of Obstetrics and Gynecology, King Saud University, Riyadh, Saudi Arabia.
¹⁰ Section of Rheumatology, Department of Internal Medicine, King Fahad Medical City, Riyadh, Saudi Arabia.
¹¹ Rheumatology Unit, Department of Medicine, Buraidah Central Hospital, B.C.H, Buraidah, Qassim, Saudi Arabia.
¹² Deputyship of Therapeutic Affairs, Ministry of Health, Riyadh, Saudi Arabia.
¹³ College of Medicine, Alfaisal University, Riyadh, Saudi Arabia.
¹⁴ Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia.
¹⁵ Department of Medicine, Section of Rheumatology, Security Forces Hospital Program, Riyadh, Saudi Arabia.
¹⁶ Division of Rheumatology, Department of Medicine, Al Hada Armed Forces Hospital, Taif, Saudi Arabia.
¹⁷ Division of Rheumatology, Department of Internal Medicine, Specialized Medical Center, Riyadh, Saudi Arabia.
¹⁸ Section of Rheumatology, Department of Internal Medicine, King Faisal Specialist Hospital and Research Center-Jeddah, Jeddah, Saudi Arabia.
¹⁹ Division of Rheumatology, Department of Internal Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia.
²⁰ Medicine Service, VA Medical Center, 700 19th St S, Birmingham, AL, 35233, USA.
²¹ Department of Medicine at the School of Medicine, University of Alabama at Birmingham (UAB), 510 20th Street S, Birmingham, AL, 35294-0022, USA.
²² Department of Epidemiology at the UAB School of Public Health, Ryals Public Health Building, 1665 University Blvd, Birmingham, AL, 35294-0022, USA.
²³ Berkshire Medical Center, Pittsfield, MA, USA.
²⁴ Yale University School of Medicine, New Haven, CT, USA.
²⁵ Department of Internal Medicine, American University of Beirut, Beirut, Lebanon.
²⁶ Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, ON, Canada.

Abstract

Background: The 2021 American College of Rheumatology (ACR) rheumatoid arthritis (RA) guideline considers the specific context of the United States which differs from that of Saudi Arabia in many aspects that may impact recommendations. The objective of this project was to adapt a set of prioritized recommendations from the 2021 ACR guideline for the treatment of rheumatoid arthritis RA for the context of Saudi Arabia, by the Saudi Society for Rheumatology (SSR).

Methods: The process followed the GRADE-ADOLOPMENT methodology, and the reporting adhered to the RIGHT-Ad@pt checklist. Working groups included a coordination group and a 19-member panel representing different stakeholder groups. The Evidence to Decision (EtD) tables included evidence on health effects from the source guideline and contextual information from the Saudi setting.

Results: The panel prioritized and adapted five recommendations from the source guideline. The process led to modifying two out of the five prioritized recommendations, all listed here. In naive patients with low disease activity, methotrexate (MTX) is conditionally recommended over sulfasalazine (SSZ) (modified direction); hydroxychloroquine (HCQ) is conditionally recommended over SSZ (unmodified). Initiation of csDMARDs with short-term glucocorticoids is conditionally recommended over csDMARDs alone in naive patients with moderate to high disease activity (modified direction). Switch to subcutaneous MTX is conditionally recommended over addition/switch to alternative DMARD(s) in patients taking oral MTX who are not at target (unmodified). Discontinuation of MTX is conditionally recommended over gradual discontinuation of the bDMARD or tsDMARD for patients taking MTX plus a bDMARD or tsDMARD who wish to discontinue a DMARD (unmodified).

Conclusion: Rheumatologists practicing in Saudi Arabia can use the adoloped recommendations generated by this project while adopting the rest of the recommendations from the 2021 ACR guidelines.

Keywords: Adaptation; Adolopment; American College of Rheumatology; Contextualization; Disease modifying anti-rheumatic drugs; Glucocorticoids; Kingdom of Saudi Arabia; Rheumatoid arthritis.

Grants and funding

UL1 TR001863/TR/NCATS NIH HHS/United States