Rheumatology Advance Access originally published online on April 28, 2009
Rheumatology 2009 48(7):765-772; doi:10.1093/rheumatology/kep073
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Contemporary treatment principles for early rheumatoid arthritis: a consensus statement
1Department of Rheumatology, St Georges Healthcare NHS Trust, London,2Department of Rheumatology, York Hospitals NHS Foundation Trust,3Department of Rheumatology, Hull & York Medical School, University of York, York,4Department of Rheumatology, Southampton University Hospitals NHS Trust, Southampton,5Department of Rheumatology, West Suffolk Hospital, Bury St Edmunds, Suffolk,6Department of Rheumatology, School of Clinical Medicine, University of Cambridge, Addenbrooke's Hospital, Cambridge,7Department of Rheumatology, Belfast Hospitals Trust, Belfast,8Kennedy Institute of Rheumatology, Faculty of Medicine, Imperial College London, London and9Section of Musculoskeletal Disease, Leeds Institute of Molecular Medicine, University of Leeds, Leeds, UK.
Correspondence to: Patrick D. W. Kiely, Department of Rheumatology, St Georges Healthcare NHS Trust, London SW17 0QT, UK. E-mail: patrick.kiely{at}stgeorges.nhs.uk
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Abstract |
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Objective. RA has a substantial impact on both patients and healthcare systems. Our objective is to advance the understanding of modern management principles in light of recent evidence concerning the condition's diagnosis and treatment.
Methods. A group of practicing UK rheumatologists formulated contemporary management principles and clinical practice recommendations concerning both diagnosis and treatment. Areas of clinical uncertainty were documented, leading to research recommendations.
Results. A fundamental concept governing treatment of RA is minimization of cumulative inflammation, referred to as the inflammation–time area under the curve (AUC). To achieve this, four core principles of management were identified: (i) detect and refer patients early, even if the diagnosis is uncertain: patients should be referred at the first suspicion of persistent inflammatory polyarthritis and rheumatology departments should provide rapid access to a diagnostic and prognostic service; (ii) treat RA immediately: optimizing outcomes with conventional DMARDs and biologics requires that effective treatment be started early—ideally within 3 months of symptom onset; (iii) tight control of inflammation in RA improves outcome: frequent assessments and an objective protocol should be used to make treatment changes that maintain low-disease activity/remission at an agreed target; (iv) consider the risk–benefit ratio and tailor treatment to each patient: differing patient, disease and drug characteristics require long-term monitoring of risks and benefits with adaptations of treatments to suit individual circumstances.
Conclusion. These principles focus on effective control of the inflammatory process in RA, but optimal uptake may require changes in service provision to accommodate appropriate care pathways.
KEY WORDS: Rheumatoid arthritis, Early rheumatoid arthritis, DMARD, Corticosteroid, Anti-TNF therapy, Tight control, Step-down therapy
Submitted 19 August 2008;
revised version accepted 9 March 2009.
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