Guideline for the management of rheumatoid arthritis (the first two years)

• British Society for Rheumatology and British Health Professionals in Rheumatology •

• A diagnosis of rheumatoid arthritis (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 or metatarsophalangeal joints or early morning stiffness of at least 30 min duration
  
• In order to identify and treat patients with RA at an early stage, it is necessary for patients with suspected early synovitis to have rapid access to a multidisciplinary team that includes specialists in rheumatology, and includes members from both primary and secondary care in order to provide a seamless service for patients
  
• Access to individual elements of the multidisciplinary service should be available according to patient need
  
• Patients with RA should be provided with a plan of care from diagnosis which outlines the principles of management including a commitment to training patients to self-manage some aspects of their disease
  
• Specialist rheumatology nurses can provide the ideal support for patients in accessing elements of the multidisciplinary team and in providing important lifestyle advice
  
• RA is a significant independent risk factor for ischaemic heart disease, with the risk related to the severity and duration of inflammation. Control of inflammation should also be accompanied by addressing each patient's other risk factors for ischaemic heart disease, using the established primary care services where appropriate
  
• All patients should have their disease and its impact assessed and documented at onset, prior to starting disease modifying anti-rheumatic drugs (DMARD) therapy. Once established on DMARD therapy, all patients should have a formal assessment of treatment response, or lack of it, 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
  
• Patients with RA should be established on disease-modifying therapy as soon as possible after a diagnosis of RA is established. Disease modifying therapy should be part of an aggressive package of care, incorporating escalating doses, intra-articular steroid injections, parenteral methotrexate and combination therapy, rather than sequential monotherapy, progressing to biologic (anti-TNF-α) therapy, when required
  
• Systemic steroid therapy may have an important early role in establishing control of synovitis or bridging disease control between different DMARD therapies but long-term use is not justified
  
• Patients with RA require assessment of both pain and optimum effective therapy to ensure early symptom control. Long-term use of non-steroidal anti-inflammatory drugs (NSAIDs) should be at the lowest effective dose
  
• Current concern over the potential cardiovascular toxicity of coxibs and NSAIDs suggests that such drugs should be avoided in high risk individuals, and used with caution in others who cannot be managed with analgesia, steroid injections and one or more DMARDs
  
• Patients with RA require early assessment of sleep patterns. Early management of sleep disturbance should include tricyclic agents, behavioural therapy and consider also the use of exercise. Consider the impact of fatigue on quality of life in early RA
  
• The evidence for the effectiveness of complementary therapy is conflicting and no firm recommendations can be made
  
• Timing and format (group/individual/written) of education to meet individual needs must be considered in early disease. Patients should be offered a cognitive behavioural approach to patient education, delivered at the appropriate time in order to promote long-term adherence to management strategies. Patients should be helped to contact support organizations such as National Rheumatoid Arthritis Society (NRAS), Arthritis Care (AC) and the Arthritis Research Campaign (ARC)
  
• Patients should be encouraged to pace activities and recognize the potential lower as well as upper limits of physical activity, facilitating a realistic readjustment of the patient's own expectations, guided by members of the multidisciplinary team. Patients should be helped to participate in exercise programmes
  
• Aerobic exercise should be encouraged to help combat the adverse effects of rheumatoid disease on muscle strength, endurance and aerobic capacity, without, in the short-term, exacerbating disease activity or joint destruction
  
• Hydrotherapy should be accessible to maximize positive effects on pain, function and self-efficacy
  
• Transcutaneous electrical nerve stimulation (TENS) use in RA patient may be effective in pain relief, but trials lack standardization
  
• Heat and cold applications may provide short-term symptomatic relief of symptoms of pain and stiffness. There is no evidence of long-lasting benefit. Paraffin wax baths combined with exercise are beneficial for hands in arthritic conditions
  
• Joint protection, energy conservation and problem-solving skills training should be taught early on in the disease course
  
• Hand function should be maintained and improved with a combination of hand exercises and appropriate devices to improve efficiency of action. Occupational therapy (OT) can be helpful for those experiencing problems at work when these are due to the symptoms of arthritis. Altering work methods, posture, pacing and assistive devices can improve functional ability
  
• When hands and wrists are painful and/or swollen, splints (hand/wrist resting splints and functional wrist splints) should be offered, but the role of splinting at other times remains uncertain
  
• The goals of foot care for patients with RA are to relieve pain, maintain function and improve quality of life using safe, cost-effective treatments such as palliative footcare, prescribed foot orthoses and specialist footwear. An annual foot review and assessment is recommended for patients at risk of developing serious complications in order to detect problems early. Foot orthoses are an important and effective intervention in RA
  
• Health professionals should provide opportunities to discuss sexuality and relationship issues where these are affected by RA. Problems may include pain, dysfunction and changes in relationships, for example dependence and loss of role. Information and help on sexuality and relationship issues should be given backed up with written leaflets and contact details of organizations who can offer support