Rheumatoid arthritis in adults: a summary of recommendations

Guideline name: Rheumatoid arthritis in adults: management [NG100]

Update type: New guideline

Published: July 2018

Takehome

• The latest NICE guidance focusses on the improvement of quality of life of individuals with rheumatoid arthritis (RA) through slowing down disease progression and controlling the symptoms.
• Urgent referral to specialists may be needed; primary investigations should not delay this.

Referral from primary care

• Refer individuals with suspected persistent synovitis of undetermined cause for specialist advice.  Refer urgently (even with a normal acute-phase response, negative anti-cyclic citrullinated peptide [CCP] antibodies or rheumatoid factor (rh-FACTOR) if any of the following apply:
  • Involvement of small joints of the hands or feet.
  • Involvement of >1 joint.
  • Delay of ≥3 months between symptom onset and seeking medical advice.

Investigations for diagnosis

If the following investigations are ordered in primary care, they should not delay referral for specialist opinion 

• Rh-factor in individuals with suspected RA with evidence of synovitis.
• Anti-CCP if individuals are negative for rh-factor.
• X-ray of hands and feet in individuals with suspected RA and persistent synovitis.

Investigations after diagnosis

• Anti-CCP antibodies, unless measured prior to diagnosis.
• X-ray of hands and feet to determine erosions unless measured prior to diagnosis.
• Measure functional ability using Health Assessment Questionnaire (HAQ), etc.
• Rapid access to specialist care is advised in case of disease worsening or flares.

Pharmacological management

• The key to RA treatment is aiming to target disease remission or low disease activity if remission cannot be achieved.
• The first line of pharmacological treatment for RA is conventional disease-modifying anti-rheumatic drug (cDMARD) monotherapy. A short-term bridging therapy with glucocorticoids should initially accompany a cDMARD.
• Further pharmacological treatment may include biological and targeted synthetic DMARDs. Short-term treatment with glucocorticoids may be used for managing flares.  

Symptom control

• Oral NSAIDs (traditional NSAIDs and cox II selective inhibitors) are suitable when pain or stiffness cannot be controlled adequately.
• When prescribing NSAIDs, it is essential to consider their potential gastrointestinal, liver and cardio-renal toxicity, and the individual’s risk factors, such as age and pregnancy.
• Oral NSAIDs should be used at the lowest effective dose for the shortest possible time preferably with a proton pump inhibitor, while monitoring the risk factors for adverse events regularly.

Monitoring

Ensure that all adults with RA have:

• Rapid access to specialist care for flares.
• Information about when and how to access specialist care.
• Ongoing drug monitoring - Consider a review appointment to take place 6 months after achieving treatment target (remission or low disease activity) to ensure that the target has been maintained.

Offer all adults with RA, including those who have achieved the treatment target, an annual review to:

• Assess disease activity and damage and measure functional ability.
• Check for the development of comorbidities, such as hypertension, ischaemic heart disease, osteoporosis and depression.
• Assess symptoms that suggest complications, such as vasculitis and disease of the cervical spine, lung or eyes.

Multidisciplinary interventions

• Individuals with RA should have ongoing access to a multidisciplinary team.
• Beneficial non-pharmacological interventions for RA patients include physiotherapy, occupational therapy, hand exercise programmes, podiatry, and psychological interventions to cope with the condition. There is no strong evidence that diet influences the condition.
• Patients may be referred for a specialist surgical opinion if optimal non-surgical management fails, if there is a risk of irreversible structural damage or deformity, or suspicion of cervical myelopathy.
• Presence of proven septic arthritis requires urgent combined medical and surgical management.

This summary is reviewed by Prof. Rishabh PrasadMBBS, MA, MSC, FRCGP FRSA