Rheumatology Advance Access originally published online on July 13, 2006
Rheumatology 2006 45(9):1167-1169; doi:10.1093/rheumatology/kel215a
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British Society for Rheumatology and British Health Professionals in Rheumatology Guideline for the Management of Rheumatoid Arthritis (the first two years)
1Nuffield Orthopaedic Centre, Oxford and University of Oxford, Oxford, 2Wirral Hospital NHS Trust, Wirral, 3Aintree University Hospital, Liverpool, 4Wansbeck General Hospital; Freeman Hospital; University of Newcastle upon Tyne, 5National Rheumatoid Arthritis Society, 6Primary Care Rheumatology Society, 7Royal National Hospital for Rheumatic Diseases, Bath, 8Robert Jones and Agnes Hunt Orthopaedic and District Hospital NHS Trust, Oswestry, Lewes Health Centre, 9Lewes, 10Arthritis Care, 11Royal College of Nursing Rheumatology Forum and Litchdon Health Centre, Barnstaple, 12Department of Podiatry and Foot Health, and Department of Orthopaedics and Trauma, Hope Hospital, Salford and 13Academic Rheumatology, City Hospital, Nottingham, UK
Correspondence to: R. Luqmani, Consultant Rheumatologist and Senior Lecturer in Rheumatology, Nuffield Orthopaedic Centre, Windmill Road, Oxford OX3 7LD, UK. E-mail: Raashid.luqmani{at}noc.anglox.nhs.uk
KEY WORDS: Rheumatoid arthritis, Guideline, Management, Disease-modifying anti-rheumatic drug therapy, Multidisciplinary care
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Scope and purpose of the guideline |
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 Top Scope and purpose of... Guideline for managing early...AcknowledgementsReferences |
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The annual incidence of rheumatoid arthritis (RA) in the UK is
24 per hundred thousand [1]. The current guideline provides practical evidence-based advice on recommended interventions in RA. The objective is to provide a framework of care for managing RA, including control of synovitis, symptom control, self-management, physical functioning, psychosocial functioning and screening/monitoring. The primary target of this guidance is health professionals and managers; however, it is also relevant to patients with RA. The guidance is limited to the first 2 yrs of RA. This is a short summary of the whole guideline. The full guideline is available on the journal website (see supplementary material for full guideline). The current guideline does not include psoriatic arthritis, disease-modifying anti-rheumatic drugs (DMARDs) or biological therapy in RA because these areas are described in separate British Society for Rheumatology (BSR) guidelines [2–4]. |
Guideline for managing early RA |
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We have produced 24 evidence-based recommendations (using Royal College of Physicians guidelines and the Appraisal of Guidelines Research and Evaluation instrument) [5, 6], each given a grade of recommendation (from A to C), and a flowchart to illustrate the care pathway for patients with RA (Fig. 1).
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Assessment/planning phase
- (1) A diagnosis of RA should be made as early as possible, on the basis of persistent joint inflammation affecting at least three joint areas, involvement of the metacarpophalangeal (MCP) or metatarsophalangeal (MTP) joints or early morning stiffness of at least 30 minutes. (C)
- (2) Patients with suspected early synovitis should have rapid access to a multidisciplinary team including specialists in rheumatology, and members from both primary and secondary care in order to provide a seamless service. (B)
- (3) Access to individual elements of the multidisciplinary service should be available according to the patient need. (B)
- (4) Patients with RA should be given a plan of care from diagnosis, including a commitment to training patients to self-manage some aspects of disease. (C)
- (5) Specialist rheumatology nurses can provide ideal support for patients in accessing elements of the multidisciplinary team and in providing important lifestyle advice. (C)
- (6) RA is a significant independent risk factor for ischaemic heart disease. Other risk factors for ischaemic heart disease should be sought and treated using primary care services. (B)
- (7) All patients should have their disease and its impact assessed and documented at onset. Once established on DMARD therapy, patients should have a formal assessment of response to treatment, in order to justify continuing therapy or changing it. Remission should be defined and documented when achieved, in order to plan reduction or maintenance therapy. (B–C)
- (2) Patients with suspected early synovitis should have rapid access to a multidisciplinary team including specialists in rheumatology, and members from both primary and secondary care in order to provide a seamless service. (B)
Deliver, stabilize and monitor care
- (8) Patients should be established on disease modifying therapy as soon as possible after a diagnosis of RA is made. Therapy should incorporate escalating doses, intra-articular steroid injections, parenteral methotrexate and combination therapy, rather than sequential monotherapy; progression to biologic (anti-TNF-
) therapy should be according to need [4]. (A)
- (9) Systemic steroids have an important early role in controlling synovitis or bridging disease control between different DMARD therapies but long-term use is not justified. (B)
- (10) Patients with RA require assessment of pain (A). Long-term use of non-steroidal anti-inflammatory drugs (NSAIDs) should be at the lowest effective dose (A).
- (11) NSAIDs should be avoided in individuals at high risk of cardiovascular morbidity, and used with caution in others who cannot be managed with analgesia, steroid injections and one or more DMARDs. (B)
- (12) Patients with RA require early assessment of sleep patterns. (A). Early management of sleep disturbance should include tricyclic agents, behavioural therapy and exercise. (B). Consider the impact of fatigue on quality of life in early RA. (B)
- (13) Evidence for effectiveness of complementary therapy is conflicting. (B)
- (14) Timing and format (group/individual/written) of education to meet individual needs should be considered. (A). Patients should be offered a cognitive behavioural approach to patient education, delivered at the appropriate time, to promote long-term adherence to management strategies (C). Patients should be helped to contact support organizations such as the National Rheumatoid Arthritis Society (NRAS), Arthritis Care (AC) and the Arthritis Research Campaign (ARC). (B)
- (15) Patients should be encouraged to pace activities and recognize the limits of physical activity, facilitating a realistic readjustment of expectations. Patients should be helped to participate in exercise programmes. (C)
- (16) Aerobic exercise should be encouraged to help combat the effects of RA on muscle strength, endurance and aerobic capacity, without, in the short-term, exacerbating disease activity or joint destruction. (B)
- (17) Hydrotherapy should be accessible to maximize positive effects on pain, function and self-efficacy. (C)
- (18) Transcutaneous electrical nerve stimulation (TENS) use in the RA patient may be effective in pain relief, but trials lack standardization. (C)
- (19) Heat and cold applications may provide short-term symptomatic relief of pain and stiffness, but there is no grade of recommendation of long-lasting benefit. Paraffin wax baths and exercise are beneficial for hands in arthritic conditions. (C)
- (20) Joint protection, energy conservation and problem-solving skills training should be taught early. (B)
- (21) Hand function should be maintained and improved with hand exercises and devices to improve efficiency. Occupational Therapy (OT) can help when problems at work are due to arthritis. Altering work methods, posture, pacing and assistive devices can improve functional ability. (C)
- (22) Painful and/or swollen hands and wrists should be splinted, but the role of splinting at other times remains uncertain. (C)
- (23) Foot care can relieve pain, maintain function and improve quality of life using safe, cost-effective treatments. An annual foot review is recommended for patients at risk of developing serious complications. (B)
- (24) Health professionals should provide opportunities to discuss sexuality and relationship issues where these are affected by RA. (C)
- (9) Systemic steroids have an important early role in controlling synovitis or bridging disease control between different DMARD therapies but long-term use is not justified. (B)
This guideline provides a framework to standardize care for patients with RA, and can be used to argue for an increase in resources or reorganization of services as appropriate, in order to improve care for all patients with RA, wherever they live in the UK.
We would recommend that audit of the RA guideline should include the assessment of the impact of the pathway on the following outcomes: synovitis; symptom control; erosive change; quality of life; self-efficacy.
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Acknowledgements |
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TopScope and purpose of...Guideline for managing early...AcknowledgementsReferences |
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This study is supported by Mooka Siyomunji-Barker in the BSR office.
S.O. has undertaken some advisory roles related to professional (nurse) education/training programmes for Abbott, Schering Plough, Wyeth, Roche and Pfizer in the last 3 yrs. F.B. has received honoraria for the research fund and/or support to attend ACR/EULAR from sponsors including MSD, Pfizer, Abbot, Schering Plough, Wyeth and Novartis.
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References |
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TopScope and purpose of...Guideline for managing early...AcknowledgementsReferences |
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- Wiles N, Symmons DPM, Harrison B, Barrett E, Barrett JH, Scott DGI, Silman AJ. (1999) Estimating the incidence of rheumatoid arthritis: trying to hit a moving target. Arthritis Rheum 42:1339–46.[CrossRef][Web of Science][Medline]
- Kyle S, Chandler D, Griffiths CE, et al. (2005) British Society for Rheumatology Standards Guidelines Audit Working Group (SGAWG). Guideline for anti-TNF-alpha therapy in psoriatic arthritis. Rheumatology 44:390–7.
[Free Full Text] - Chakravarty K, McDonald H, Pullar T, et al. (2006) Guideline for DMARD therapy in rheumatic diseases. Rheumatology (In press).
- Ledingham J and Deighton C. (2005) Update on the British Society for Rheumatology guidelines for prescribing TNF blockers in adults with rheumatoid arthritis (update of previous guidelines of April 2001). Rheumatology 44:157–63.
[Free Full Text] - http://www.rcplondon.ac.uk/college/ceeu/conciseGuidelineDevelopmentNotes.pdf.
- www.agreecollaboration.org.
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