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Rheumatoid arthritis in adults: management

Key priorities for implementation

Referral for specialist treatment

  • Refer for specialist opinion any person with suspected persistent synovitis of undetermined cause
  • Refer urgently if any of the following apply:
    • the small joints of the hands or feet are affected
    • more than one joint is affected
    • there has been a delay of 3 months or longer between onset of symptoms and seeking medical advice

Disease-modifying and biological drugs

  • In people with newly diagnosed active RA, offer a combination of disease-modifying antirheumatic drugs (DMARDs) (including methotrexate and at least one other DMARD, plus short term glucocorticoids) as first-line treatment as soon as possible, ideally within 3 months of the onset of persistent symptoms
  • In people with newly diagnosed RA for whom combination DMARD therapy is not appropriate (for example, because of comorbities or pregnancy, during which certain drugs would be contraindicated), start DMARD monotherapy, placing greater emphasis on fast escalation to a clinically effective dose rather than on the choice of DMARD
  • In people with recent-onset RA receiving combination DMARD therapy and in whom sustained and satisfactory levels of disease control have been achieved, cautiously try to reduce drug doses to levels that still maintain disease control

Monitoring disease

  • In people with recent-onset active RA, measure C-reactive protein (CRP) and key components of disease activity (using a composite score such as DAS28) monthly until treatment has controlled the disease to a level previously agreed with the person with RA

Biologicals

  • Anakinra is not recommended for treating RA, except in a controlled, long-term clinical study
  • Patients already receiving anakinra should continue therapy until they and their consultant consider it is appropriate to stop
  • Do not offer anakinra with tumour necrosis factor-α (TNF-α) therapy

Glucocorticoids

  • Offer short-term treatment for flares
  • Consider short-term treatment if people are not already taking glucocorticoids as part of DMARD combination therapy
  • For established RA, continue long-term treatment only when:
    • complications have been fully discussed, and
    • all other treatments have been offered

Symptom control

  • Offer analgesics if pain control is not adequate
  • If offering a non-steroidal anti-inflammatory drug (NSAID) or a cyclo-oxygenase 2 (COX-2) inhibitor, offer a standard drug (but not etoricoxib 60 mg) as a first choice. Co-prescribe with a proton pump inhibitor (choose the least expensive drug)
  • Prescribe NSAIDs/COX-2 inhibitors at the lowest effective dose for the shortest time possible
  • Because of the potential gastrointestinal, liver and cardio-renal toxicity of NSAIDs/COX-2 inhibitors:
    • take into account individual patient risk factors, including age, when choosing the drug and dose
    • assess and/or monitor patient risk factors
    • consider other analgesics if the patient is already taking low-dose aspirin for another condition
  • If NSAIDs/COX-2 inhibitors do not control symptoms satisfactorily, review the DMARD/biological drug regimen

The multidisciplinary team

  • People with RA should have access to a named member of the multidisciplinary team (MDT) (for example, the specialist nurse) who is responsible for coordinating their care

Surgery

  • Do not let concerns about the long-term durability of prosthetic joints influence decisions to offer joint replacements to younger people. If offering surgery, explain that the main expected benefits are:
    • pain relief
    • improvement, or prevention of further deterioration, of joint function, and
    • prevention of deformity

Monitoring and review

All people with RA

  • Offer annual review to:
    • assess disease activity and damage, and
    • measure functional ability
    • check for comorbidities such as hypertension, ischaemic heart disease, osteoporosis and depression
    • check for complications such as vasculitis and disease of the cervical spine, lung or eyes
    • organise cross-referral within the MDT
    • assess the need for referral for surgery
    • assess the effect RA is having on the person’s life
  • Measure CRP and key components of disease activity regularly to inform decision-making about increasing or decreasing treatment

Recent-onset active RA

  • Measure CRP and key components of disease activity monthly until disease is controlled to an agreed level

Controlled established RA

  • Offer review appointments at a frequency and location suitable to people’s needs
  • Make sure people:
    • have access to additional visits for flares
    • know when and how to access specialist care rapidly
    • have ongoing drug monitoring
Referral, diagnosis, and investigations
INDICATIONACTION
Suspected persistent synovitis of unknown cause Refer for specialist opinion
Suspected persistent synovitis of unknown cause, plus any of the following:
  • small joints of hands or feet affected
  • more than one joint affected
  • symptoms were present for 3 months or longer before presentation
Refer urgently for specialist opinion, even if the person has a normal acute-phase response or is negative for rheumatoid factor
Synovitis on clinical examination plus suspected RA Offer to test for rheumatoid factor
Persistent synovitis affecting hands and feet X-ray
Suspected RA plus negative rheumatoid factor Consider testing anti-cyclic citrullinated
peptide (CCP) antibodies to inform decision making about starting combination therapy

Pharmacological management

NICE - RA Algorithm

Referral for surgery
INDICATIONACTION
Any of the following that do not respond to optimal non-surgical management:
  • persistent pain because of joint damage or other soft-tissue cause
  • worsening joint function
  • progressive deformity
  • persistent localised synovitis
Offer to refer for an early specialist surgical opinion.
Any of the following:
  • imminent or actual tendon rupture
  • nerve compression
  • stress fracture
Offer to refer for a specialist surgical opinion before damage or deformity becomes irreversible
Suspected or proven septic arthritis Offer urgent combined medical and surgical management
Symptoms or signs suggesting cervical myelopathy Request an urgent MRI scan and refer for a specialist surgical opinion

full guideline available from…
National Institute for Health and Care Excellence, Level 1A, City Tower, Piccadilly Plaza, Manchester, M1 4BT
www.nice.org.uk/guidance/CG79

National Institute for Health and Care Excellence. Rheumatoid arthritis in adults: management. May 2009
First included: June 2009.