Rheumatoid arthritis: the management of rheumatoid arthritis in adults

National Institute for Health and Clinical Excellence

Key priorities for implementation

Referral for specialist treatment

• Refer for specialist opinion any person with suspected persistent synovitis of undetermined cause

• Refer urgently if any of the following apply:
• the small joints of the hands or feet are affected
• more than one joint is affected
• there has been a delay of 3 months or longer between onset of symptoms and seeking medical advice

Disease-modifying and biological drugs

• In people with newly diagnosed active RA, offer a combination of disease-modifying antirheumatic drugs (DMARDs) (including methotrexate and at least one other DMARD, plus short term glucocorticoids) as first-line treatment as soon as possible, ideally within 3 months of the onset of persistent symptoms

• In people with newly diagnosed RA for whom combination DMARD therapy is not appropriate (for example, because of comorbities or pregnancy, during which certain drugs would be contraindicated), start DMARD monotherapy, placing greater emphasis on fast escalation to a clinically effective dose rather than on the choice of DMARD

• In people with recent-onset RA receiving combination DMARD therapy and in whom sustained and satisfactory levels of disease control have been achieved, cautiously try to reduce drug doses to levels that still maintain disease control

Monitoring disease

• In people with recent-onset active RA, measure C-reactive protein (CRP) and key components of disease activity (using a composite score such as DAS28) monthly until treatment has controlled the disease to a level previously agreed with the person with RA

Biologicals

• Anakinra is not recommended for treating RA, except in a controlled, long-term clinical study

• Patients already receiving anakinra should continue therapy until they and their consultant consider it is appropriate to stop

• Do not offer anakinra with tumour necrosis factor-α (TNF-α) therapy

Glucocorticoids

• Offer short-term treatment for flares

• Consider short-term treatment if people are not already taking glucocorticoids as part of DMARD combination therapy

• For established RA, continue long-term treatment only when:
• complications have been fully discussed, and
• all other treatments have been offered

Symptom control

• Offer analgesics if pain control is not adequate

• If offering a non-steroidal anti-inflammatory drug (NSAID) or a cyclo-oxygenase 2 (COX-2) inhibitor, offer a standard drug (but not etoricoxib 60 mg) as a first choice. Co-prescribe with a proton pump inhibitor (choose the least expensive drug)

• Prescribe NSAIDs/COX-2 inhibitors at the lowest effective dose for the shortest time possible

• Because of the potential gastrointestinal, liver and cardio-renal toxicity of NSAIDs/COX-2 inhibitors:
• take into account individual patient risk factors, including age, when choosing the drug and dose
• assess and/or monitor patient risk factors
• consider other analgesics if the patient is already taking low-dose aspirin for another condition

• If NSAIDs/COX-2 inhibitors do not control symptoms satisfactorily, review the DMARD/biological drug regimen