Quality appraisal of clinical practice guidelines and consensus statements on the use of biologic agents in rheumatoid arthritis: A systematic review

Objective. To evaluate the quality of clinical practice guidelines (CPGs) and consensus statements (CS) for the treatment of rheumatoid arthritis with tumor necrosis factor α (TNFα) antagonists. Methods. We searched for CPGs and CS on the use of infliximab, etanercept, and/or adalimumab for the treatment of rheumatoid arthritis, published through October 10, 2006. Sources included electronic databases (Medline, EMBase, BIOSIS, etc.), guideline registries, and pertinent Web sites. Review of 4,915 citations revealed 16 CPGs and 20 CS. Two independent reviewers evaluated development methods of selected studies using the 23-item Appraisal of Guidelines for Research and Evaluation (AGREE) instrument and compared recommendations between guidelines. Results. Of the 16 guidelines, only 5 (31%) were based on a systematic review of relevant research evidence. Only 4 (25%) of the guidelines fulfilled ≥60% of the AGREE criteria. AGREE scores were lower for guidelines from rheumatology societies than government agencies when reporting scope and purposes (P = 0.03), stakeholder involvement (P = 0.03), and clarity and presentation (P = 0.01). Guidelines scored higher than CS in most domains. Overall, guideline recommendations were consistent with respect to the use of biologic agents after failure of disease-modifying antirheumatic drugs, but differed or did not provide specific guidance on tests for screening. Conclusion. Guidelines for introducing TNFα antagonists in rheumatoid arthritis often fail to meet expected methodologic criteria and therefore vary significantly in quality and with respect to some recommendations for patient assessment and management.