27th February 2009
The NICE guideline (CG79) covers the management of rheumatoid arthritis (RA) of recent onset and more established disease. It includes sections on diagnosis and referral, pharmacological and surgical management and the role of the multidisciplinary team.
The quick reference guide is worth reading by all who have any involvement in the care of people with RA: specialist staff will of course need to become familiar with the whole guideline. In primary care, one of the most important components of the guidance is the recommendation to refer for specialist opinion any person with suspected persistent synovitis of undetermined cause, urgently in some cases. NICE advises that urgent referral should still be made even if blood tests show a normal acute-phase response or negative rheumatoid factor.
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, start DMARD monotherapy, placing greater emphasis on fast escalation to a clinically effective dose rather than on the choice of DMARD. Circumstances in which combination DMARD therapy might not be appropriate include the presence of comorbidities, or pregnancy, during which certain drugs would be contraindicated.
- 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.
- 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.
The multidisciplinary team
- People with RA should have access to a named member of the multidisciplinary team (for example, the specialist nurse) who is responsible for coordinating their care.
NICE also gives advice on surgical options, diet and use of complementary therapies