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ACR Clinical Guidelines Flawed by Low Evidence

JAMA Internal Medicine has reported that recommendations and clinical practice guidelines (CPGs) from the American College of Rheumatology (ACR) are often based on expert opinion, but lack rigorous (grade A) evidence to support many of their recommendations. (Citation source:

Researchers compiled eight published rheumatology CPGs endorsed by the ACR and studied the the level of evidence and strength of the recommendations.  

Specifically this included clinical practice guidelines covering glucocorticoid-induced osteoporosis (GIOP), juvenile idiopathic arthritis (JIA), gout, lupus nephritis, osteoarthritis (OA), ankylosing spondylitis (SpA), polymyalgia rheumatica (PMR), and rheumatoid arthritis (RA). 

These 8 guidelines included 403 recommendations, with more than half (58%) based on level C evidence (meaning on expert opinion, case studies, or standard of care).

Importantly, only 23% of these recommendations were based on level A evidence (based on multiple randomized clinical trials or meta-analyses); and one-fifth were level B (single RCT or nonrandomized studies).

The proportion of recommendations supported by A-level evidence ranged from 2% for juvenile idiopathic arthritis and 10% for polymyalgia rheumatica to 35% for glucocorticoid-induced osteoporosis and 58% for osteoarthritis.

Obviously, societal guidelines carry significant weight with patients, payors, and agencies dedicated to cost-efficient and effective care for the population. With an aging society, there is a belief that guidelines for arthritis management will be pivotal. Yet the authors question the utility of guidelines largely based on no evidence, weak evidence and expert opinion. 

The most commonly observed support was the combination of C-level evidence and class II strength (benefit greater than or equal to harm); this was seen in roughly 30% of the guidelines  and in 50% of the RA recommendations.

The quality of ACR guidelines is similar to that seen with other subspecialty guidelines, including cardiology, infectious diseases, nephrology, etc.

The authors point out that some guideline recommendations do have high levels of evidence and strength and that such guidelines merit greater adherence and implementation.

The authors conclude that the evidence supporting ACR recommendations is limited, with more than 50% of  recommendations classified as level C.  While the ACR has adopted the GRADE system of evidence evaluation to control for some of these deficits, the redefinition of level A evidence and the inclusion of real world evidence may improve the certainty, if not applicability, of future guidelines.

The author has no conflicts of interest to disclose related to this subject

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