NICE guidance on RA updates prescribing and test advice

Updated NICE guidance on RA backs anti-CCP antibody testing for all patients diagnosed with the condition and treatment with a single conventional disease modifying anti-rheumatic drug (cDMARD) rather than a combination.

Advice on referral from primary care says GPs should refer for specialist opinion 'any adult with suspected persistent synovitis of undetermined cause'.

An urgent referral is required 'even with a normal acute-phase response, negative anti-CCP antibodies or rheumatoid factor' if the small joints of the hands or feet, or more than one joint is affected, or where patients have waited more than three months since symptoms began before seeking medical advice.

In an overhaul of prescribing advice for RA, the guideline recommends starting treatment with a single cDMARD rather than a combination, as previous advice recommended. The change reflects evidence that treatment begun with a combination of the drugs was no more effective.

Prescribing advice

Further cDMARDs can be added if dose escalation fails to achieve remission or low disease activity, NICE says. Steroids can also be considered as a bridging treatment for patients starting a new DMARD.

The guidance says: 'The 2018 recommendations to start with monotherapy and add drugs when the response is inadequate are unlikely to have a substantial impact on practice or resources, as they align with the current approach taken by many healthcare professionals.

'However, the recommendations should result in a more consistent treatment strategy and reduce the number of people prescribed combination therapy on diagnosis.'


The updated advice also says clinicians should 'consider oral non-steroidal anti-inflammatory drugs (NSAIDs, including traditional NSAIDs and cox II selective inhibitors), when control of pain or stiffness is inadequate'.

When choosing this option, clinicians should take account of risk factors and offer the lowest effective dose for the shortest possible time, a proton pump inhibitor (PPI), and review risk factors for adverse events regularly.

Around 1.5 men and 3.6 women develop RA per 10,000 people per yearm, with incidence highest among men and women in their 70s. NICE says the changes recommended 'are fully achievable within existing NHS resources'.

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