Features a holistic assessment algorithm and treatment options. Overview This guideline covers diagnosing and managing rheumatoid arthritis. 1 The decision means that people with severe RA may now benefit from upadacitinib, which is the only treatment to have demonstrated improved … What has proved challenging for some rheumatologists was the recommendation in the 2009 guideline to follow patients monthly until their target was met. It is recommended that CCP, CRP and X-rays are arranged at initial diagnosis in secondary care if they were not undertaken before referral. Although labour intensive, this approach may prove cost effective by reducing the number of patients who need to be prescribed a bDMARD. July 2018. www.nice.org.uk/guidance/ng100 (accessed September 2019). Offer to refer adults with RA for an early specialist surgical opinion if any of the following do not respond to optimal non-surgical management: persistent pain due to joint damage or other identifiable soft tissue cause. Consider a tailored strengthening and stretching hand exercise programme for adults with RA with pain and dysfunction of the hands or wrists if: they have been on a stable drug regimen for RA for at least 3 months, The tailored hand exercise programme for adults with RA should be delivered by a practitioner with training and skills in this area, All adults with RA and foot problems should have access to a podiatrist for assessment and periodic review of their foot health needs, Functional insoles and therapeutic footwear should be available for all adults with RA if indicated, Offer psychological interventions (for example, relaxation, stress management and cognitive coping skills), Inform adults with RA who wish to experiment with their diet that there is no strong evidence that their arthritis will benefit. In addition, there may be challenges to health professionals in primary and secondary care when explaining risk factors for progression to some patients. No. This guideline is the basis of QS33. Once a patient has achieved and maintained their treatment target of remission or low disease activity for at least a year without glucocorticoids, the guideline recommends the rheumatologist should consider cautiously reducing drug doses or stopping drugs in a step-down strategy but to return promptly to the previous DMARD regimen if the treatment target is no longer met. However, they could be encouraged to follow the principles of a Mediterranean diet (more bread, fruit, vegetables and fish; less meat; and replace butter and cheese with products based on vegetable and plant oils), Inform adults with RA who wish to try complementary therapies that although some may provide short-term symptomatic benefit, there is little or no evidence for their long-term efficacy. Adults with RA should have access to specialist occupational therapy, with periodic review, if they have: difficulties with any of their everyday activities. NICE publishes evidence-based recommendations for health and care in England (not Wales or Scotland, although they can also be used there). If you continue to use the site, we will assume you are happy to accept the cookies anyway. Throughout the course of their disease, offer them the opportunity to talk about and agree all aspects of their care, and respect the decisions they make. Rational therapy in RA: Issues in implementing a treat-to-target approach in RA. NICE Bites is a monthly prescribing bulletin published by North West Medicines Information centre which summarises key recommendations from NICE guidance. Kyburz D et al; physicians of SCQM-RA. Achieving the target may involve trying multiple conventional disease-modifying anti-rheumatic drugs (cDMARDs) and biological DMARDs with different mechanisms of action, one after the other, Consider making the target remission rather than low disease activity for people with an increased risk of radiological progression (presence of anti-CCP antibodies or erosions on X-ray at baseline assessment), In adults with active RA, measure C-reactive protein (CRP) and disease activity (using a composite score such as DAS28) monthly in specialist care until the target of remission or low disease activity is achieved, Explain the risks and benefits of treatment options to adults with RA in ways that can be easily understood. Summary; Have I got the right topic? (Technical appraisal 27). NICE also publishes quality standards in the form of statements that are designed for commissioners and providers to identify gaps in service provision and areas for improvement, to facilitate measurement of quality of care and demonstration of high quality care, with the aim to facilitate commissioning of high quality services. Allen A(1), Carville S(1), McKenna F(2); Guideline Development Group. The guideline committee were unable to strengthen the recommendation and advise all patients to receive bridging therapy because of the lack of research evidence. Rheumatoid arthritis in adults: management. Thereafter, if the patient remains with severe active disease (DAS>5.1) they would be eligible for a bDMARD. This is in order to emphasise the importance of the patient monitoring their condition and seeking rapid access to specialist care if disease worsens or they have a flare. The quality standards for RA were last published in 2013 but are currently being revised. In February 2009, NICE published the first clinical guideline (CG) on Rheumatoid arthritis in adults: management (CG79), with the aim of improving early detection of rheumatoid arthritis (RA) in primary care and ensuring prompt referral to specialist care. When positive, anti-cyclic citrullinated peptide (CCP) antibodies and/or radiographic erosions at diagnosis in combination with a raised C-reactive protein (CRP) are indicators of a poor prognosis. Refer urgently (even with a normal acute-phase response, negative anti-cyclic citrullinated peptide [CCP] antibodies or rheumatoid factor) if any of the following apply: the small joints of the hands or feet are affected, there has been a delay of 3 months or longer between onset of symptoms and seeking medical advice, If the following investigations are ordered in primary care, they should not delay referral for specialist opinion, Offer to carry out a blood test for rheumatoid factor in adults with suspected rheumatoid arthritis (RA) who are found to have synovitis on clinical examination, Consider measuring anti-CCP antibodies in adults with suspected RA if they are negative for rheumatoid factor, X-ray the hands and feet in adults with suspected RA and persistent synovitis. When treating symptoms of RA with oral NSAIDs: offer the lowest effective dose for the shortest possible time, review risk factors for adverse events regularly, If a person with RA needs to take low-dose aspirin, healthcare professionals should consider other treatments before adding an NSAID (with a PPI) if pain relief is ineffective or insufficient, Adults with RA should have ongoing access to a multidisciplinary team. BSR's 'gold standard' clinical guidelines support evidence-based clinical practice in rheumatology. Topics A to Z; Specialities; What's new ; About CKS; Journals and databases; Read about our approach to COVID-19. It typically affects the small joints of the hands and the feet, and usually both sides equally and symmetrically, although any synovial joint can be affected. The content on this page is intended for UK healthcare professionals only. The early signs of RA of joint pain and swelling usually present in primary care. NICE recommends upadacitinib for severe rheumatoid arthritis. Rheumatol Int 2017;37:179–87. Some rheumatologists who have not adopted a treat-to-target strategy may need a change in practice. NICE Bites No 109 July/August 2018 includes one topic: Rheumatoid arthritis in adults. This is surprising to those who consider methotrexate to be superior although this is not supported by current data. This will require revision of local protocols in order that step-up protocols may be implemented rather than initial combination therapy. For example, with the DAS28, remission is a score of <2.6 and low disease activity is ≤3.2. Cohen MD, Keystone EC. RA typically presents as inflammatory arthritis affecting the small joints of the hands and the feet (usually both sides equally and symmetrically) although any synovial joint can be involved. Approximately 1% of the UK population have RA, and as many as 15% of these people may have severe active disease at any point in time. This guideline covers diagnosing and managing rheumatoid arthritis. Our guidelines grow out of the collaborative efforts of many members and non-members, specialists and generalists, patients and carers. Commissioners and Trusts are expected to adhere to NICE guidelines and to assure the process through regular audit. The guideline is relevant to non-specialist health professionals who are involved in the initial assessment of RA symptoms and ongoing care of people diagnosed with RA. Rheumatoid arthritis in adults: management: NICE guideline (NG100). NICE does not recommend a preference for first line therapy [ NICE, 2018a ], however the ACR suggests that methotrexate should be the preferred initial treatment for most people with rheumatoid arthritis [ ACR, 2015 ], and EULAR recommends that methotrexate should be part of the first treatment strategy for people at risk of persistent disease, unless contraindicated [ Combe, 2016 ]. NICE accepts no responsibility for the use of its content in this product/publication. One problem with csDMARDS is that they have a gradual onset of action over weeks to months. Ultrasound scanning of joints is increasing, and the recommendation not to use ultrasound routinely may need to be reflected in the revision of local protocols. Sethi MK, O’Dell JR. Diagnosis and management of rheumatoid arthritis in adults: summary of updated NICE guidance. It aims to improve quality of life by ensuring that people with rheumatoid arthritis have the right treatment to slow the progression of their condition and control their symptoms. The availability of specialist nurses is often instrumental in supporting these recommendations and service planning should consider the resources required to deliver both monthly monitoring and annual review. In addition, In view of the considerable difference in cost between subcutaneous and oral methotrexate, further research needs to be undertaken to determine whether there is greater efficacy of subcutaneous methotrexate compared with oral therapy. Research is also needed to identify the best use of corticosteroids in RA, and whether ultrasound can improve management. Refer all people suspected of having RA for specialist assessment. NICE Pathways; NICE guidance; Standards and indicators; Evidence search; BNF; BNFC; CKS. Although current evidence suggests that all people with RA should be offered the same management strategy, it is possible that those identified with a risk of poor prognosis should be treated differently. Recommendations for identifying and managing ‘long-COVID’ in primary care, Commissioned by Intercept Pharma UK and Ireland Ltd. Thereafter it is recommended that patients should have a review appointment after six months to ensure that the target has been maintained and if stable to be reviewed at least on an annual basis. and rheumatoid arthritis. [B] Cosmetic improvements should not be the dominant concern. This is more challenging than the recommendation in 2009 and could have resource implications as patients might have more treatment and follow up appointments. NICE CG79 recommended that, once in specialist care, patients received early treatment with disease-modifying anti-rheumatic drugs (DMARDs). The recommendation to especially target patients with poor prognostic markers will need to be included in new protocols. This guideline was developed by a multidisciplinary expert panel: Cooper C et al with the support of an educational grant from UCB Pharma Ltd. Available from: www.nice.org.uk/NG100. However, the evidence for this approach was re-evaluated and a meta-analysis did not find superiority for any individual drug. The express aim of the Institute is to prevent ill health, to promote and protect good health, to improve the quality of care and services and to adapt and provide health and social care services. Last revised in April 2020. Refer urgently (even with a normal acute-phase response, negative anti-cyclic citrullinated peptide [CCP] antibodies or rheumatoid factor) if any of the following apply: 1.1. the small joints of the hands or feet a… This site uses cookies, some may have been set already. Topics A to Z; Specialities; What's new; About CKS; Journals and databases; Read about our approach to COVID-19. Katherine Laight. Patients with a DAS28 between 3.2 and 5.1 are often referred to as having moderate disease and at present NICE do not have guidance for this group of patients if they have failed csDMARDs; they are not currently eligible for a bDMARD or tsDAMRD unless they have a DAS28 >5.1. The recommendations and evidence in chapters 7 and 8 have been stood down and replaced. The guidelines are widely used to define ‘minimum standards of care’ in the UK, so that patients and carers using the National Health Service (NHS) know what they are entitled to receive from healthcare providers. Rheumatoid arthritis (RA) is an inflammatory disease largely affecting synovial joints. Helapet launches new product datasheet look with new online archive. New NICE guidelines focus on managing the long-term effects of COVID-19, and vitamin D use in the context of COVID‑19, A clear, concise summary of NICE’s guideline on the care and management of osteoarthritis. Registered in the United Kingdom. The committee found very limited evidence for paracetamol, opioids, and tricyclic antidepressants for symptom control in rheumatoid arthritis, so the recommendation for “other analgesics” was removed from the update of this guideline and replaced with a recommendation for NSAIDs alone – to consider oral non-steroidal anti-inflammatory drugs (NSAIDs), including traditional NSAIDs and COX II selective inhibitors, when control of pain or stiffness is inadequate taking account of potential gastrointestinal, liver, and cardio-renal toxicity, and the person’s risk factors, including age and pregnancy. 2147432 cogora.com, Subscribe to Hospital Pharmacy Europe newsletter and magazine, FDA approval for ILUVIEN® in DME strengthens Alimera Sciences in global ophthalmology arena, EMA updates guidance on insomnia medication, Robots revolutionise dispensing in hospitals, Feedback: Automation systems in your hospital, Helapet introduce new, improved 20mm Vented Vial Adapter, User-friendly osteoporosis therapy launched, Recent progress in drug treatments for cancer, Cytostatics and the challenge of documenting stabilities, Boehringer Ingelheim initiates Phase III clinical trial with novel oral agent in advanced breast cancer, Early conversations crucial in management of type 2 diabetes, Rapid referral based on clinical examination alone, Treat to target of remission or low disease activity, csDMARD monotherapy then step up combination, The small joints of the hands or feet are affected. We systematically reviewed current guidelines for managing rheumatoid arthritis (RA) to evaluate their range and nature, assess variations in their recommendations and highlight divergence in their perspectives. Overview This guideline covers the recognition, diagnosis and early … Author information: (1)National Guideline Centre, Royal College of Physicians, London NW1 4LE, UK. If an adult with RA decides to try complementary therapies, advise them: these approaches should not replace conventional treatment, this should not prejudice the attitudes of members of the multidisciplinary team, or affect the care offered, rapid access to specialist care for flares. However, flares of disease are characteristic of many patients with RA and there should be rapid access to specialist care for flares and this is emphasised in the guideline. Welcome to Guidelines. However, although this may have resource implications the recommendation remains that all patients should be reviewed monthly in their rheumatology unit until they are in remission or low disease state. The guideline recommends referral in any patient when: Referral should be guided by clinical examination and should not be delayed by waiting for results of any investigations as they may be normal especially in early disease. The guideline emphasises the importance of rapid referral to a rheumatologist for any adult with suspected persistent synovitis of undetermined cause independent of investigations including blood tests for acute phase response or rheumatoid factor. In patients with newly diagnosed active rheumatoid arthritis, monotherapy with a conventional disease-modifying antirheumatic drug (DMARD), either oral methotrexate, leflunomide, or sulfasalazine, should be given as first-line treatment; hydroxychloroquine sulfate, a weak DMARD, is an alternative in patients with mild rheumatoid arthritis or those with palindromic rheumatism. Offer verbal and written information to adults with RA to: improve their understanding of the condition and its management, Adults with RA who wish to know more about their disease and its management should be offered the opportunity to take part in existing educational activities, including self-management programmes, See Algorithm 2 for rheumatoid arthritis management and monitoring, Consider oral non-steroidal anti-inflammatory drugs (NSAIDs, including traditional NSAIDs and cox II selective inhibitors), when control of pain or stiffness is inadequate. In addition, although the use of ultrasound has expanded in rheumatology as well as other specialties, the role of ultrasound in the management of RA is unclear.5 Following an extensive literature review the conclusion in the guideline was not to recommend ultrasonography for routine monitoring of disease activity in adults with RA. Nat Rev Rheumatol 2013;9:137–8. All rights reserved. Cogora Limited, 140 London Wall, London EC2Y 5DN. A high priority research recommendation has been included to answer this question. A. Abdominal aortic aneurysm; Abortion care; Accident prevention (see unintentional injuries among under-15s) Acute coronary syndromes: early management; Acute coronary syndromes: When patients with RA have met their target, monitoring patients on DMARDs should be shared between primary and secondary care. In order to provide a rapid reduction in symptoms, most rheumatologists recommend short term bridging treatment with glucocorticoids (oral, intramuscular, or intra-articular). Although control of synovitis with csDMARD and corticosteroids improves symptoms, some patients require additional analgesia. It aims to improve quality of The National Institute for Clinical Excellence (NICE) clinical practice guidelines, published in February 2009, which address RA and place patients at the centre of care, have been greeted with a broadly positive reaction. In July 2018, the National Institute for Health and Care Excellence (NICE) published revised guidelines for the management of rheumatoid arthritis (RA) disease in adults. As soon as possible after establishing a diagnosis of RA: measure anti-CCP antibodies, unless already measured to inform diagnosis, X-ray the hands and feet to establish whether erosions are present, unless X-rays were performed to inform diagnosis, measure functional ability using, for example, the Health Assessment Questionnaire (HAQ), to provide a baseline for assessing the functional response to treatment. National Institute for Health and Care Excellence. July 2018: NICE has made new recommendations on treat-to-target strategy, initial pharmacological management, symptom control and monitoring. An annual review was also included in the previous guideline but many rheumatologists have found a comprehensive review to be difficult to deliver. The role of ultrasound in diagnosing rheumatoid arthritis, what do we know? The guideline recommends that the rheumatologist should inform those with risk factors of a poor prognosis that they have an increased risk of radiological progression. If anti-CCP antibodies are present or there are erosions on X-ray: advise the person that they have an increased risk of radiological progression but not necessarily an increased risk of poor function, emphasise the importance of monitoring their condition, and seeking rapid access to specialist care if disease worsens or they have a flare, see Algorithm 1 for referral, diagnosis, and investigations, Treat active RA in adults with the aim of achieving a target of remission or low disease activity if remission cannot be achieved (treat-to-target). This guideline replaces CG79. This site is intended for UK healthcare professionals, Guidelines Live 2020—now available on demand, depression in adults with a chronic physical health problem, Non-alcoholic steatohepatitis: identification, management, and referral pathways, New COVID guidelines focus on long-term effects and vitamin D. Refer for specialist opinion any adult with suspected persistent synovitis of undetermined cause.
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