Here's what I learned at ACR23 that will change the way I practice in rheumatoid arthritis. 

The possibility of withdrawing DMARDs after patients achieve remission has been in our minds for a while. Yet when our patients ask whether it is a good idea to taper or stop their DMARD when they are doing well, most of us don’t have a black or white answer for them.

We have become accustomed to the 60/40/20% rule for the outcome of ACR 20/50/70 respectively for biologics and targeted synthetic DMARDs.

There is not a single one of us in rheumatology who hasn’t prescribed steroids, but we really need to reconsider how much and how often we use them.

TNF inhibitors revolutionised the treatment of rheumatoid arthritis. While highly effective for the joint manifestations of the disease, a note of caution was sounded regarding the potential for worsening of ILD with these agents. Within this framework, a study by England et al presented at ACR23 was highly relevant.

Most rheumatologists, if asked, would say that every rheumatoid arthritis patient should be started on a DMARD of some sort - if not at diagnosis, then pretty soon after. So I am genuinely shocked that, in a large United States Medicare 20% sample dataset between 2008-17, less than 30% of new RA patients aged 66 years or older have a DMARD initiated.

Remission had been a dream, an elusive concept. But then, with the introduction of biologics, conventional synthetic and targeted synthetic DMARDS, patients are able to live longer and with a better quality of life. While these therapeutics have been helpful, they are expensive and carry potential side effects. The big question looms: Do we stop or continue treatment?

You can see that the JAKi/TYK2i have both approved or potential seropositive and seronegative indications. There are also improvements in PsO for the class and studies in CTDs. So, it is difficult to know which to choose.

Drs. Jack Cush and Arthur Kavanaugh discuss highlights and key takeaways from ACR 23.

While there wasn’t much original new programming and research presented on the final day, that didn’t slow the RheumNow faculty from tweeting the noteworthy “Best of ACR” abstracts. Enjoy these below.