This week NICE released its guidance on the management of rheumatoid arthritis (RA).1
The key points of this guidance that relate to primary care are discussed here.
RA is an inflammatory disease affecting the joints and tendons and any tissues with synovial membranes. It commonly affects 1 per cent of the population.
Approximately one-third of patients cease work because of the disease within two years of onset.
The total costs of RA in the UK, including indirect costs and work-related disability, have been estimated at between £3.8 billion and £4.7 billion per year.
Treatment for RA has to be started early in the disease to prevent disease progression. Patients who wait over a year from symptom onset to referral to a rheumatologist still have a 73 per cent risk of developing erosive change prior to treatment being initiated.2
Patients with erosive disease have more progressive disease and greater disability.
The distribution of joints affected in RA is characteristic. It typically affects the small joints of the hands and the feet, usually in a symmetrical distribution, although any synovial joint can be affected.
In patients with established and aggressive disease, most joints will eventually be affected.
It is a systemic disease and can affect the whole body, including the heart, lungs and eyes.
Traditionally, guidelines on when to refer patients on to specialist care were cumbersome and not useful for primary care.
While developing the new NICE guidelines, the development group felt that it was very important that the referral guideline was useful for primary care.
The new guideline recommends that GPs refer for specialist opinion any case of 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 three months or longer between onset of symptoms and seeking medical advice.
There are still challenges. How can GPs spot these patients among the huge number of patients consulting with musculoskeletal problems?
Evidence shows that patients often delay presentation to their GP;3 this may be because public knowledge about RA is poor.
The guidelines recommend GPs do not avoid referring urgently any patient with suspected persistent synovitis of undetermined cause whose blood tests show a normal acute-phase response or negative rheumatoid factor.
In early arthritis, acute phase reactants may not be elevated. This should not delay referral.
All doctors therefore need to remain alert to the possibility that a patient may have an inflammatory arthritis.
According to NICE, GPs should consider measuring anti-cyclic citrullinated peptide (CCP) antibodies in patients with suspected RA if they are negative for rheumatoid factor, and there is a need to inform decision-making about starting combination therapy.
Some GPs will have access to anti-CCP measurements; it is a more specific test for RA. It is however, much more expensive than the test for rheumatoid factor.
Rheumatoid factor in most studies is a useful predictor of RA development.
The guidelines also recommend X-rays of hands and feet early in the disease, so it may be important for GPs to arrange these at the same time as referral.
Patients with RA should be offered verbal and written information to improve their understanding of the condition and its management and counter possible misconceptions.
At the time of initial specialist referral, it should be normal practice to give patients some information about what to expect when they are seen at the hospital and what the course of their disease is likely to be.
A good source of specific patient information is the Arthritis Research Campaign (see www.arc.org.uk).
Patients 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 and mood) and help to manage the condition.
Patients will often present first to primary care and return with flare-ups or complications of the disease. The primary care team will often be responsible for drug monitoring, particularly of DMARDs.
Patients with newly diagnosed active RA should be offered a combination of DMARDs (including methotrexate and at least one other, plus short-term glucocorticoids) as first-line treatment as soon as possible, ideally within three months of the onset of persistent symptoms.
GPs should be aware that patients may be started on more than one DMARD as part of
more aggressive therapy for RA.
There is no evidence that these patients have more complications or side-effects but they have better outcomes.As GPs it is our job to support patients in this initial phase and not to discourage them from taking the drugs. We should make ourselves aware of potential side-effects and why we need to undertake blood monitoring. We should be better informed and therefore able to reassure patients about minor side-effects.
NICE also advises that specialist units should also make themselves more accessible to answer questions from primary care.
Use of steroids
Patients should be offered short-term treatment with glucocorticoids for managing flares with recent-onset or
established disease, to rapidly decrease inflammation.
In patients with established RA, long-term treatment should only be continued with glucocorticoids when the long-term complications of such therapy have been fully discussed, and all other treatment options (including biologicals) have been offered and tried if accepted.
It is acceptable to use short-term steroids to control flares of disease. Take guidance from specialist units if there is uncertainty. Patients should not be left on steroids for the long term.
Any patients who are being maintained on long-term steroids should be referred to specialist care for assessment or reassessment. It is no longer acceptable to manage patients in primary care on steroids alone.
The recommendations state that simple analgesics should be used in preference to long-term NSAIDs. If the use of NSAIDs is inevitable, they should be used with proton pump inhibitors. Each patient should be considered with their co-morbidities when choosing a NSAID or COX-2 inhibitor. Similarly, patients should be monitored for the consequences of taking the NSAID.
Patients often worry about their diet and whether it will affect their arthritis. No evidence of this was found and the guideline simply recommends a Mediterranean diet with plenty of fresh fruit and vegetables.
Alternative and complementary therapies are not discouraged, but no evidence was found for any of them regarding
improvement in symptoms or outcomes in the disease.
Patients with RA who decide to try complementary therapies should be advised that these approaches should not replace conventional treatment and that this will not prejudice the attitudes of members of the multidisciplinary team to the patient, or affect the care offered.
This guideline has offered primary care robust help in when to refer patients with suspected RA. It also acknowledges the role GPs play in the management of RA, which is a life-long condition.
Although an annual review is suggested, the place of this review is not defined. Patients with RA have an increased risk of cardiovascular events (approaching that in diabetes).
Irrespective of where the annual review takes place, we should be monitoring these co-morbidities in primary care.
Inclusion of musculoskeletal disorders in the quality framework would acknowledge the work already being done and improve standards of care.
- Dr Warburton is a GPSI in rheumatology in Ironbridge, Shropshire and a member of the NICE guideline development group
1. NICE. Rheumatoid arthritis: clinical guideline. London: National Institute for Health and Clinical Excellence, Feb 2009.
2. Irvine S, Munro R, Porter D. Early referral, diagnosis and treatment of rheumatoid arthritis: evidence for changing medical practice. Ann Rheum Dis 1999; 58: 510–3.
3. Kumar K, Daley E, Carruthers DM et al. Delay in presentation to primary care physicians is the main reason why patients with rheumatoid arthritis are seen late by rheumatologists. Rheumatology (Oxford) 2007; 46: 1,438-40.