Rheumatologist
Evidence & Updates
Guideline changes that affect referral and triage, newest first. Reviewed October 2026.
Guideline updates
- September 2026
ACR 2026 osteoarthritis guideline update
Summary approved by the ACR Board in September 2026; full manuscript forthcoming.
- New: a GLP-1 receptor agonist, with diet and exercise, for knee OA with obesity (conditional).
- Changed: methotrexate is now conditionally recommended for erosive hand OA; glucosamine and chondroitin are now strongly recommended against; massage is now conditionally recommended.
- Strongly against: platelet-rich plasma, stem cell injections, hydroxychloroquine and bisphosphonates for OA. Conditionally against: hyaluronic acid injections and opioids.
- July 2026
EULAR 2025 recommendations for PMR and large-vessel vasculitis
Published in Annals of the Rheumatic Diseases, 2026.
- All suspected PMR, GCA and Takayasu arteritis warrant rapid specialist referral; suspected cranial GCA is an emergency, with urgent specialist referral within 24 hours.
- A glucocorticoid trial should not be used as a diagnostic test. In PMR and Takayasu, treatment can usually wait until the workup is complete; in GCA, start immediately when suspicion is high.
- Dosing: PMR 15–25 mg/day, reaching 10 mg/day within 2 months; GCA 40–60 mg/day, reaching 15–20 mg/day by months 2–3.
- Steroid-sparing: sarilumab preferred for relapsing or refractory PMR, tocilizumab for selected new PMR; tocilizumab or upadacitinib for GCA; methotrexate as an alternative.
- May 2026
ACR/SAA/SPARTAN 2026 axial spondyloarthritis guideline
Approved by the ACR Board in May 2026.
- Imaging: an AP pelvis radiograph first (over lumbar spine or dedicated SI joint films); SI joint MRI without contrast if non-diagnostic. In children, SI joint MRI without contrast.
- NSAIDs and physical therapy remain first-line; TNF or IL-17 inhibitors are strongly recommended after NSAIDs, with JAK inhibitors as an alternative. IL-23 inhibitors are strongly recommended against in axSpA.
- Continuing an originator biologic is conditionally preferred over switching to a biosimilar for patients doing well.
- Ask every patient about uveitis and IBD; strongly recommends against opioids and spinal manipulation.
- February 2026
ACR 2026 juvenile idiopathic arthritis guidelines
Approved by the ACR Board in February 2026; full manuscripts forthcoming.
- Systemic JIA: IL-1 or IL-6 inhibitors first-line; with MAS, add systemic glucocorticoids. Avoid NSAIDs, csDMARDs or oral glucocorticoids alone.
- Polyarthritis: DMARDs first-line, methotrexate the preferred csDMARD and a TNF inhibitor the preferred first biologic. Oligoarthritis: intra-articular glucocorticoids first-line.
- Uveitis: screening every 3 months for high-risk children; methotrexate then adalimumab when topical steroids are still needed.
- New monitoring intervals for methotrexate, NSAIDs, hydroxychloroquine and biologics, and a strong recommendation for structured transition planning.
- 2026
Other updates published in 2026
- EULAR updates on RA management (2025 update), Behçet's syndrome (2025 update) and physical activity in inflammatory arthritis and OA (2025 update).
- BSR guideline on the treatment of polymyalgia rheumatica (2026).
- Late 2025
ACR 2025 SLE guideline
- Hydroxychloroquine is recommended for nearly everyone with SLE, with attention to dose and retinal screening.
- Glucocorticoids should be minimized, with early use of steroid-sparing immunosuppressive or biologic therapy.
- Applies to children and adults; accompanies the ACR 2024 lupus nephritis guideline.
- November 2025
BSR 2025 csDMARD prescribing and monitoring guideline
- Risk-adaptive monitoring: bloods at week 2 and then monthly for the first 3–6 months; about every 3 months once stable, with longer intervals possible after an individual risk review.
- Review trends; most isolated abnormalities don't need a treatment change.
- Adults may withhold methotrexate for up to 2 weeks after influenza or COVID-19 vaccination where disease allows.
- Covers children for the first time; suggests varicella (and, in children, measles) immunity checks before starting, and FIB-4 assessment for methotrexate patients with liver risk factors.
- 2025
Lupus nephritis, CTD-ILD and pregnancy guidance
- EULAR 2025 lupus nephritis update, alongside the ACR 2024 lupus nephritis guideline.
- ERS/EULAR 2025 CTD-ILD guidelines: screen everyone with systemic sclerosis, MCTD or inflammatory myositis (except inclusion body myositis) with HRCT; screen RA and Sjögren's disease when risk factors are present.
- EULAR 2024 update on antirheumatic drugs in reproduction, pregnancy and lactation (published 2025): TNF inhibitors can continue throughout pregnancy; methotrexate up to 25 mg/week may be considered during breastfeeding if there is no alternative; men can continue methotrexate (25 mg/week or less), mycophenolate and leflunomide.
- 2025
Screening, classification and other 2025 guidance
- USPSTF 2025: osteoporosis screening for women 65 and older and younger postmenopausal women at increased risk; evidence insufficient for men.
- EULAR/ACR 2025 classification criteria for pediatric chronic nonbacterial osteomyelitis.
- BSR 2025 guidelines for ANCA-associated vasculitis and for biologic and targeted therapy in axSpA.
- 2023–2024
Still relevant from 2023–2024
- ACR/CHEST 2023 ILD screening and treatment guidelines (PFTs and HRCT for screening).
- AHA 2024 Kawasaki disease update; CDC 2023 MIS-C case definition; CDC 2023 hepatitis B screening (triple panel).
- EULAR/PReS 2024 Still's disease and FMF recommendations; EULAR 2023 SLE, systemic sclerosis, psoriatic arthritis and large-vessel vasculitis imaging recommendations.
- BSR 2024 systemic sclerosis and Sjögren's disease guidelines; BAD/BSR 2024 Behçet's guideline.
Sources
- ACR/CHEST 2023 ILD screening guideline
- AHA 2024 Kawasaki disease update
- CDC MIS-C case definition
- CDC 2023 hepatitis B screening recommendations
- EULAR/PReS 2024 Still's disease recommendations
- EULAR/PReS 2024 FMF recommendations
- EULAR 2023 SLE recommendations
- EULAR 2023 systemic sclerosis recommendations
- EULAR 2023 PsA recommendations
- EULAR 2023 imaging in large-vessel vasculitis
- BSR 2024 systemic sclerosis guideline
- BSR 2024 Sjögren disease guideline
- BAD/BSR 2024 Behçet's living guideline
Recent FDA approvals relevant to referral
| Approved | Medicine | Indication |
|---|---|---|
| March 2026 | Deucravacitinib (Sotyktu) | Active psoriatic arthritis (first TYK2 inhibitor for PsA) |
| October 2025 | Obinutuzumab (Gazyva) | Lupus nephritis |
| August 2025 | Sublingual cyclobenzaprine (Tonmya) | Fibromyalgia |
| June 2025 | Emapalumab (Gamifant) | HLH/MAS in known or suspected Still's disease (including systemic JIA) with an inadequate response or intolerance to glucocorticoids, or recurrent MAS |
| April 2025 | Upadacitinib (Rinvoq) | Giant cell arteritis |
| April 2025 | Inebilizumab (Uplizna) | IgG4-related disease (first approved treatment) |
Sources
- FDA approval of deucravacitinib for PsA (March 2026)
- FDA approval of obinutuzumab for lupus nephritis (October 2025)
- FDA approval of sublingual cyclobenzaprine for fibromyalgia (August 2025)
- FDA approval of emapalumab for MAS in Still's disease (June 2025)
- FDA approval of upadacitinib for GCA (2025)
- FDA approval of inebilizumab for IgG4-RD (April 2025)
Referral, triage and workforce evidence
Referral letters often miss what triage needs
In 206 referrals to one outpatient rheumatology clinic, 47% changed urgency grade between referral and consultation, and 17% were upgraded to urgent. For the truly urgent cases, letters lacked a presumptive diagnosis, symptom duration or the joints involved in over 30%.
Central triage can shorten waits for inflammatory arthritis
After centralized triage and quality-improvement changes at one academic center, the mean wait for suspected inflammatory arthritis or connective tissue disease fell from 33.8 to 15.5 days, while waits for non-inflammatory problems rose from 37.3 to 52.2 days (retrospective, single center).
Machine learning may sharpen referral triage
In 2,265 patients from a German online referral system, machine-learning models improved discrimination of inflammatory rheumatic disease (AUROC up to 0.737, from 0.534) and roughly doubled specificity at 90% sensitivity. A 2025 Dutch study of GP referral letters reported AUCs of 0.78 for RA, 0.71 for OA and 0.81 for fibromyalgia.
Demand is projected to outstrip supply
The 2015 ACR Workforce Study (Battafarano et al., 2018) projected that by 2030 demand for adult rheumatology care would exceed supply by 102%, as clinical supply falls by about 25%. The study report projected that about 50% of adult rheumatologists would retire by 2030, and in patient surveys 27% reported more than 4 months from symptom onset to seeing a rheumatologist.
The workforce grew, but not enough
The clinically active rheumatology workforce grew by more than 20% over the 2010s, but the authors note that demand for rheumatologic care still exceeds supply.
Structured pathways and advice services
National and regional pathways (for example, the BSR's specialist advice and triage guidance and the South East London referral and triage guidelines) set out which problems to refer, which to manage locally, and which to redirect, alongside advice-and-guidance services.