July 2018: NICE has made new recommendations on treat-to-target strategy, initial pharmacological management, symptom control and monitoring. The recommendations and evidence in chapters 7 and 8 have been stood down and replaced.

There are over 400,000 people with rheumatoid arthritis (RA) in the UK. Although this makes it a common disorder, there are numerous other conditions ahead of it in terms of numbers, and indeed as causes of excess mortality. What this does not capture however, is the dreadful morbidity associated with the disease. The synovitis of RA affects multiple sites causing widespread pain, and the subsequent destruction of the joints can lead to severe disability affecting all aspects of motor function from walking to fine movements of the hand. Furthermore, RA is not simply a disease of the joints but can affect many other organs causing, for example, widespread vasculitis or severe lung fibrosis. More recently it has become apparent that RA is associated with an increased prevalence of coronary artery disease and significant increased risk of premature mortality.

Fortunately there are a considerable number of disease-modifying and anti-inflammatory agents which can significantly reduce the impact of RA. Some of these, for example corticosteroids, sulphasalazine or methotrexate, have been available for many years, and rheumatologists are well used to balancing the benefits and side-effects of these drugs. More recently, targeted diseasemodifying and anti-inflammatory therapies, particularly the anti-TNF agents, have emerged, and have proved effective in many patients. While it is encouraging that there is such a wide range of treatment available, the choice brings with it difficult questions concerning the best sequencing of therapy. Moreover, the newer drugs are expensive. The high impact of the disease and the need to make best use of the available treatment make RA a highly suitable subject for a NICE guideline, which it is now my pleasure to introduce.

I have already touched on the exciting therapeutic options for RA, but this guideline addresses many other aspects of management. Because established RA has so many classical features it is easy to forget that at presentation the diagnosis may not be readily apparent, yet early intervention may be important. The guideline offers advice on this problem, including a consideration of the place of newer serological markers of the disease, particularly anti-CCP antibodies. The role of objective measures in the monitoring of disease activity is also considered, as an important component of achieving and maintaining control. The importance of non-pharmacological management of RA is also emphasised, including the many therapeutic interventions which are usually supervised by physiotherapists, occupational therapists and podiatrists; as is the crucial role of the multidisciplinary team including these professionals as well as specialist nurses and doctors.

Contents

• Guideline Development Group members
• Acknowledgements
• Preface
• Acronyms, abbreviations and glossary
• Development of the Guideline
  • 1. Introduction
    • 1.1. Background
    • 1.2. Definition
    • 1.3. Prevalence and incidence
    • 1.4. Management principles
    • 1.5. Health and resource burden
    • 1.6. Living with RA
  • 2. Methodology
    • 2.1. Aim
    • 2.2. Scope
    • 2.3. Audience
    • 2.4. Involvement of people with RA
    • 2.5. Guideline limitations
    • 2.6. Other work relevant to the guideline
    • 2.7. Background
    • 2.8. The process of guideline development
    • 2.9. Disclaimer
    • 2.10. Funding
  • 3. Key messages of the guideline
    • 3.1. Key priorities for implementation
    • 3.2. Algorithm
• The Guideline
  • 4. Referral, diagnosis and investigations
    • 4.1. Referral for specialist services
    • 4.2. Presenting symptoms and signs
    • 4.3. Investigations
  • 5. Communication and education
    • 5.1. Patient perceptions and beliefs
    • 5.2. Patient education
  • 6. The multidisciplinary team
    • 6.1. The multidisciplinary team
    • 6.2. Physiotherapy
    • 6.3. Occupational therapy
    • 6.4. Podiatry
  • 7. Pharmacological management
    • 7.1. Disease modifying antirheumatic drugs (DMARDs)
    • 7.2. Glucocorticoids
    • 7.3. Biologics
    • 7.4. Symptom control
  • 8. Monitoring rheumatoid arthritis
    • 8.1. Monitoring disease
    • 8.2. Content and frequency of review
    • 8.3. Timing and referral for surgery
  • 9. Other aspects and treatment
    • 9.1. Diet
    • 9.2. Complementary therapies
  • 10. NICE technology appraisal related recommendations
  • 11. Areas for future research
• References
• Appendices
  • Appendix A. Clinical questions and literature search
  • Appendix B. Scope of the guideline
  • Appendix C. Disease modifying antirheumatic drug combinations in early rheumatoid arthritis: a cost-effective analysis
  • Appendix D. Declaration of interests (GDG members)
• Evidence Tables

Royal College of Physicians: The Royal College of Physicians plays a leading role in the delivery of high-quality patient care by setting standards of medical practice and promoting clinical excellence. We provide physicians in the United Kingdom and overseas with education, training and support throughout their careers. As an independent body representing over 20,000 Fellows and Members worldwide, we advise and work with government, the public, patients and other professions to improve health and healthcare.

National Collaborating Centre for Chronic Conditions: The National Collaborating Centre for Chronic Conditions (NCC-CC) is a collaborative, multiprofessional centre undertaking commissions to develop clinical guidance for the National Health Service (NHS) in England and Wales. The NCC-CC was established in 2001. It is an independent body, housed within the Clinical Standards Department at the Royal College of Physicians of London. The NCC-CC is funded by the National Institute for Health and Clinical Excellence (NICE) to undertake commissions for national clinical guidelines on an annual rolling programme.

Suggested citation:

National Collaborating Centre for Chronic Conditions. Rheumatoid arthritis: national clinical guideline for management and treatment in adults. London: Royal College of Physicians, February 2009.