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who have moderate-to-high disease activity despite csDMARD monotherapy This recommendation is based on the lower expected risk of NTM lung disease associated with csDMARDs compared to bDMARDs and tsDMARDs (56). Abatacept is conditionally recommended over other bDMARDs and tsDMARDs for patients with NTM lung disease who have moderate-tohigh disease activity despite csDMARDs Abatacept is conditionally recommended over other bDMARDs and tsDMARDs based on population data extrapolated from studies on tuberculosis (57). There is considerable uncertainty regarding the risk of mycobacterial infections associated with non–TNF inhibitor bDMARDs and tsDMARDs; however, TNF inhibitors are associated with increased rates of mycobacterial infections and should be avoided (58). 936 FRAENKEL ET AL | The preceding 3 recommendations are conditional because of the very low-certainty evidence supporting the analysis of the differences in treatment outcomes posed by these PICO questions. DISCUSSION The ACR guidelines were developed to provide clinicians with recommendations for decisions frequently faced in clinical practice. Several new topics are included in this update, including recommendations for administration of methotrexate, use of methotrexate in patients with subcutaneous nodules, pulmonary disease, and NAFLD, use of rituximab in patients with hypogammaglobulinemia, and treatment of RA in patients with NTM lung disease. Areas covered in the 2015 guidelines that are not covered in this update include recommendations for patients with hepatitis C and solid malignancies. The panel did not vote on specific recommendations for patients with hepatitis C because curative antiviral therapy is now widely available. The panel did deliberate over PICO questions related to use of DMARDs in patients with solid malignancies. However, given the changing landscape of personalized treatments for many solid malignancies, the voting panel felt that a generalized recommendation was not possible. On February 4, 2021, the FDA released a Drug Safety Alert noting a possible increased risk of major cardiovascular events and malignancies (excluding non-melanoma skin cancer) in patients with RA (over the age of 50 years with at least 1 risk factor for cardiovascular disease) participating in a randomized controlled trial designed to compare the safety of tofacitinib to adalimumab (18). Recommendations will be reviewed once peerreviewed results are published. Rapidly evolving comparative effectiveness and safety signals associated with JAK inhibitors highlight the need to engage in a shared decision-making process when adjusting DMARDs (16,59). In addition, although previous recommendations cautioned against the use of TNF inhibitors in patients with skin cancer (1), the results of more recently published studies examining specific DMARD-related risks of nonmelanoma skin cancer and melanoma do not support making a definite recommendation for or against specific DMARDs (60,61). The panel also considered PICO questions related to current use of checkpoint inhibitor therapy, but the variability in current practice patterns and differences in treatment for specific cancer types precluded the development of specific recommendations for patients who are candidates for, or are currently receiving checkpoint inhibitor therapy. We anticipate that additional recommendations for patients with systemic rheumatic diseases and solid malignancies will be developed as further data become available. There were vigorous discussions pertaining to recommendations for specific DMARDs in patients with moderate-tohigh disease activity despite csDMARDs and with a history of serious infection. However, the evidence was insufficient to support a
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