Table 1.

Comparison of three guidelines recommending dose-titration in rheumatoid arthritis

Guideline	Method for reviewing and rating quality of evidence	Recommendation	Quality of evidence
2015 ACR Guideline for the Treatment of Rheumatoid Arthritis [3]	GRADEa methodology was used to evaluate the literature	For patients with established RA who are in remission:	Conditional recommendation
		Taper DMARD therapy	Low
		Taper TNF-I, non-TNF biologic or tofacitinib	Moderate to very low
EULAR recommendations for the management of RA: 2013 update [6]	Most evidence came from three SLRs; provides levels of evidence, grades of recommendations, and strengths of recommendations	If a patient persists in remission after tapering glucocorticoids, then the clinician can consider tapering bDMARDs, especially if combined with a csDMARD	LoE:b 2b GoR: B SoR: 8.7 ± 1.8 Votes: 100%
APLAR RA treatment recommendations [7]	The ADAPTE framework was used to identify and review international RA guidelines, and the AGREE II instrument was used to assess the quality of the guidelines	Tapering of bDMARDs can be considered for patients in extended remission (>12 months)	LoE: 2 Strength: B

ACR American College of Rheumatology, AGREE Appraisal of Guidelines, Research and Evaluation, bDMARD biologic DMARD, csDMARD conventional synthetic DMARD, EULAR European League Against Rheumatism, GoR grade of recommendation, GRADE Grading of Recommendations Assessment, Development and Evaluation, LoE level of evidence, RA rheumatoid arthritis, SLR systematic literature review, SoR strength of recommendation (level of agreement), TNF tumor necrosis factor

^aGroup consensus was used to determine whether the recommendations were strong or conditional. A strong recommendation denotes that clinicians feel certain the benefits of an intervention are greater than the harms (or vice versa). A conditional recommendation indicates that clinicians are uncertain of the balance between benefits and harms, and/or significant variability exists in patient values and preferences. Evidence was rated as low quality or moderate to very low quality because some of the evidence was indirect (studies included discontinuation rather than tapering of therapy or patients achieved low disease activity rather than remission)

^bLoE and GoR are based on recommendations from the Oxford Centre for Evidence-Based Medicine