Recommendations for the treatment of rheumatoid arthritis (RA) in patients with cancer often fail to meet expected methodologic criteria, according to a recent study. Therefore, there was agreement on the need for caution when prescribing disease-modifying antirheumatic drugs (DMARDs) to these patients. Researchers searched electronic databases, guideline registries, and relevant websites for cancer‐specific recommendations on RA management. Reviewers independently selected and appraised the recommendations according to the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument. They identified similarities and discrepancies among recommendations and found:
- Of 4,077 unique citations, 39 recommendations were identified of which half described their consensus process.
- Average scores for the AGREE II domains ranged from 33% to 87%.
- Cancer risk in RA was addressed in 79% of recommendations, with acknowledgement of increased overall cancer risk.
- Recommendations did not agree on the safety of using DMARDs in RA patients with cancer, except for the contraindication of tumor necrosis factor inhibitors in patients at risk for lymphoma.
- Most recommendations agreed that RA treatment should be stopped and re‐evaluated with a new diagnosis of cancer.
Lopez-Olivo MA, Colmegna I, Karpes AR, et al. Systematic review of recommendations on the use of disease‐modifying antirheumatic drugs in patients with rheumatoid arthritis and cancer. [Published online ahead of print March 1, 2019]. Arthritis Care Res. doi:10.1002/acr.23865.
Cancer is a much-feared complication of both rheumatoid arthritis and its treatment. While rheumatologists generally agree on the increased risk of lymphoma in RA patients on anti-TNF agents, the impact of other DMARDs on cancer risk (especially other types of cancer) has been less well-examined. This systematic review addresses published cancer-specific recommendations for RA patients and found a reasonable consensus on the overall increased risk of cancer and suggestion to stop DMARDs in RA patients who are newly diagnosed with cancer. There is also a consensus that RA patients should be screened for cancer prior to initiation and during treatment with DMARDs, but not specifically what types of cancer or how they should be monitored. In addition, earlier recommendations regarding DMARD use in patients with a prior history of cancer were more restrictive in terms of contraindication vs use with caution. This study highlights the lack of consensus on non-TNF biologic and synthetic DMARD safety in RA patients with cancer and the need for research in order to better guide clinical practice. —Arundathi Jayatilleke, MD