NICE (The National Institute for Health and Care Excellence) has listed evidence-based recommendations for healthcare professionals on the management of rheumatoid arthritis in adults. These guidelines can be referred to while treatment planning.

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Referral from primary care

Refer for a specialist opinion if the patient has suspected persistent synovitis of undetermined cause. It is important to urgently refer (even with a normal acute-phase response, negative anti-cyclic citrullinated peptide [CCP] antibodies or rheumatoid factor) if:

• 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 the onset of symptoms and seeking medical advice

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Investigations

1. Blood test for suspected rheumatoid arthritis (RA) who are found to have synovitis on clinical examination
2. Measurement of anti-CCP antibodies in adults with suspected RA if they are negative for rheumatoid factor
3. Radiograph of hands and feet to establish whether erosions are present
4. Measure functional ability using any form of health assessment questionnaire for assessing the functional response to treatment
5. If anti-CCP antibodies are present or there are erosions on X-ray:
   1. Advise the patient about the increased risk of radiological progression but not necessarily an increased risk of poor function.
   2. Emphasise the importance of monitoring their condition, and seeking rapid access to specialist care if the disease worsens or in case of a flare.

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Treat-to-target strategy

Treat active RA in adults with the aim of achieving a target of remission or low disease activity if remission cannot be achieved. 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 and antibodies or erosions on X-ray at baseline assessment. In adults with active RA, measure C-reactive protein (CRP) and disease activity until the target of remission or low disease activity is achieved.

Communication and education

Explain the risks and benefits of treatment options to the patient. Throughout the course of their disease, offer them the opportunity to talk about and agree on all aspects of their care, and also respect the decisions they make. Offer verbal and written information to improve their understanding of the condition and its management, and counter any misconceptions they may have.

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Initial pharmacological management

Conventional disease-modifying anti-rheumatic drugs

For adults with newly diagnosed active RA:

• Offer first-line treatment with cDMARD monotherapy using oral methotrexate, leflunomide or sulfasalazine as soon as possible and ideally within 3 months of the onset of persistent symptoms
• Consider hydroxychloroquine for first-line treatment as an alternative to oral methotrexate, leflunomide or sulfasalazine for mild or palindromic disease
• Escalate dose as tolerated by the patient

Consider short-term bridging treatment with glucocorticoids (oral, intramuscular or intra-articular) when starting a new cDMARD. Offer additional cDMARDs in combination in a step-up strategy when the treatment target (remission or low disease activity) has not been achieved despite dose escalation.

Biological and targeted synthetic DMARDs

The 2009 guideline committee reviewed the evidence on Anakinra and incorporated the recommendations into the guideline. The technology appraisal was then withdrawn. On the balance of its clinical benefits and cost-effectiveness, Anakinra is not recommended for the treatment of RA, except in the context of a controlled, long-term clinical study.

Patients currently receiving Anakinra may suffer the loss of wellbeing if their treatment were discontinued at a time they did not anticipate. Therefore, patients should continue therapy with Anakinra until they and their consultant consider it is appropriate to stop. It has also been recommended to not offer the combination of tumour necrosis factor-α (TNF-α) inhibitor therapy and Anakinra.

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Glucocorticoids

Offer short-term treatment with glucocorticoids for managing flares in adults with recent-onset or established disease to rapidly decrease inflammation. In adults with established RA, only continue long-term treatment with glucocorticoids when:

• The long-term complications of glucocorticoid therapy have been fully discussed
• All other treatment options (including biological and targeted synthetic DMARDs) have been offered

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Symptom control

Consider oral NSAIDs (including traditional NSAIDs and cox II selective inhibitors), when control of pain or stiffness is inadequate. Take account of potential gastrointestinal, liver and cardio-renal toxicity, and the person's risk factors, including age and pregnancy. When treating symptoms of RA with oral NSAIDs:

• Offer the lowest effective dose for the shortest possible time
• Offer a proton pump inhibitor (PPI)
• 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.

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Non-pharmacological management

Physiotherapy

Patients should be offered physiotherapy, with periodic review to:

• Improve general fitness and encourage regular exercise
• To enhance joint flexibility, muscle strength and managing other functional impairments
• Learn about the short-term pain relief provided by methods such as transcutaneous electrical nerve stimulators (TENS), etc.

Hand exercise programmes

Consider a customised strengthening and stretching hand exercise programme of the hands or wrists if:

• they are not on a drug regimen for RA, or
• they have been on a stable drug regimen for RA for at least 3 months

Podiatry

Patients should be offered a podiatrist for assessment and periodic review of their foot health needs. Functional insoles and therapeutic footwear should be recommended if indicated.

Psychological interventions

Offer psychological interventions like relaxation, stress management and cognitive coping skills [such as managing negative thinking].

Diet and complementary therapies

Patients should be encouraged to follow a more natural diet consisting of more bread, fruit, vegetables and fish; less meat; and replace butter and cheese with products based on vegetable and plant oils.

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Monitoring

Consider a review appointment to take place 6 months after achieving the treatment target (remission or low disease activity) to ensure that the target has been maintained. Offer patients 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 of complications, such as vasculitis and disease of the cervical spine, lungs or eyes
• Assess the need for referral for surgery

For adults who have maintained the treatment target (remission or low disease activity) for at least 1 year without glucocorticoids, consider cautiously reducing drug doses or stopping drugs in a step-down strategy. Return promptly to the previous DMARD regimen if the treatment target is no longer met. Do not use ultrasound for routine monitoring of disease activity in adults with RA.

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Timing and referral for surgery

1. Refer for a specialist surgical opinion if any of the following is experienced. Do not respond to optimal non-surgical management.
   1. Persistent pain due to joint damage or other identifiable soft tissue cause
   2. Worsening joint function
   3. Progressive deformity
   4. Persistent localised synovitis
2. Offer to refer patients with the following complications for a specialist surgical opinion before damage or deformity becomes irreversible:
   1. Imminent or actual tendon rupture
   2. Nerve compression (for example, carpal tunnel syndrome)
   3. Stress fracture
3. Explain to the patient the main expected benefits of the surgery:
   1. Pain relief
   2. Improvement, or prevention of further deterioration, of joint function, and prevention of deformity
   3. Cosmetic improvements should not be the dominant concern
4. Consider urgent combined medical and surgical management to adults who have suspected or proven septic arthritis (especially in a prosthetic joint). If an adult with RA develops any symptoms or signs that suggest cervical myelopathy (for example, paraesthesia, weakness, unsteadiness, reduced power, or extensor plantars), request an urgent MRI scan, and refer for a specialist surgical opinion.
5. Do not let concerns about the long-term durability of prosthetic joints influence decisions to offer joint replacements to younger adults with RA.

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Conclusion

Conventional DMARDs are synthetic drugs that modify disease rather than just alleviating symptoms. Additional DMARDs are added to DMARD monotherapy when the disease is not adequately controlled. During treatment with 2 or more DMARDs, tapering and stopping at least 1 drug once the disease is adequately controlled. Adults with RA should have ongoing access to a multidisciplinary team. This should provide the opportunity for periodic assessments of the effect of the disease on their lives (such as pain, fatigue, everyday activities, mobility, ability to work or take part in social or leisure activities, quality of life, mood, impact on sexual relationships) and help to manage the condition.