Rheumatoid arthritis

1. Rheumatoid arthritis Key slides

2. Aims of treatmentNICE Clinical Guideline 79. February 2009 Three main aims of treatment: • relief of symptoms, especially pain • disease modification, to help slow or stop disease progression, and maintain and preserve function • support to help patients cope with and manage the effects of RA on their lives. Key priorities in NICE guidance • Prompt referral for specialist treatment • Early use of disease-modifyingdrugs • Effective monitoring of disease • Access to a multi-disciplinary team.

3. What NICE covers NICE Clinical Guideline 79. February 2009 • Referral, diagnosis and investigations • Communication and education • The multidisciplinary team • Pharmacological management • Monitoring RA • Timing and referral for surgery • Diet and complementary therapies.

4. Referral, diagnosis and investigationsNICE Clinical Guideline 79. February 2009 • 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 • Do not avoid referring urgently any person with suspected persistent synovitis of undetermined cause whose blood tests show a normal acute-phase response or negative rheumatoid factor.

5. The multidisciplinary teamNICE Clinical Guideline 79. February 2009 • People with RA should have ongoing access to an MDT. This should provide the opportunity for periodic assessments of the effect of the disease on their lives and help to manage the condition • People with RA should have access to: • a named member of the MDT (for example, the specialist nurse) who is responsible for coordinating their care • specialist physiotherapy • specialist occupational therapy • a podiatrist • Offer psychological interventions to help people with RA adjust to living with their condition.

6. Monitoring RANICE Clinical Guideline 79. February 2009 • Measure CRP and key components of disease activity (using a composite score such as DAS28) regularly in people with RA to inform decision-making about increasing or decreasing treatment for disease control • In people with recent-onset active RA, measure CRP and key components of disease activity (using a composite score such as DAS28) monthly until treatment has controlled the disease to a previously agreed level • Offer people with satisfactorily controlled established RA review appointments at a frequency and location suitable to their needs • Ensure ongoing drug monitoring and rapid access to specialist care e.g. during flares • Offer a comprehensive, holistic, annual review.

7. Pharmacological management NICE Clinical Guideline 79. February 2009 • Early intervention with DMARDs • Combination therapy, including methotrexate plus at least one other DMARD, plus short-term glucocorticoid • If combination therapy not appropriate, start DMARD monotherapy (fast escalation more important than drug choice) • Cautiously try to reduce doses once sustained control obtained • Symptom control with analgesics and/or NSAIDs • Glucocorticoids to gain control of disease and manage flares • Avoid long-term use unless essential • Biological drugs if inadequate response to DMARDs.

8. Symptom controlNICE Clinical Guideline 79 & NICE Full Guideline. February 2009 • Analgesics and NSAIDs can be very useful in controlling the painful symptoms of RA • Analgesics are first choice and may reduce the need for NSAIDs, or at least reduce the dose required • NSAIDs are useful but consider the GI and CV risks • Co-prescribing a PPI with a standard NSAID reduces the GI risks substantially • No good evidence that adding a PPI to a coxib is more beneficial than adding a PPI to a traditional NSAID • People with RA have a higher baseline CV risk than similar people with OA, so the absolute CV risks of NSAIDs may well be greater • No apparent increase in thrombotic risks with ibuprofen ≤1200mg/day or naproxen 1g/day.

9. Biological drugsNICE Clinical Guideline 79. February 2009 • Anakinra and abatacept▼ not recommended by NICE • Adalimunab▼, etanercept▼andinfliximab recommended as options in patients with DAS28 >5.1 • Must have tried two DMARDs, including methotrexate • Continue only if maintain improvement of ≥1.2 pts on DAS28 • Can change to another anti-TNF if not tolerated • Guidance awaited on sequential use if treatment failure • Rituximab▼ recommended as second-line biologic • Continue only if maintain improvement of ≥1.2 pts on DAS 28 • Certolizumab, golimumabandtocilizumab▼ are coming • Beware of side-effects, especially infections and heart failure.

10. Overall summary: Three steps to RA heavenBased on NICE Clinical Guideline 79. February 2009 • Identify and refer people promptly • Any patient withsuspected persistent synovitis of undetermined cause, urgently if ≥3 months since onset of symptoms • Start DMARDs promptly • Ideally within 3 months of the onset of persistent symptoms • Use a combination, including methotrexate plus short-term glucocorticoid • If combination therapy is not possible it’s more important to get to an effective dose quickly than worry about choice of DMARD • Use analgesics, NSAIDs and short-term glucocorticoids to manage pain and flares • Consider biological drugs in line with NICE guidance • Monitor response using CRP and DAS28 and try stepping down when the patient’s disease is stable • Offer support to help people manage the effects of RA • The MDT is key, with access to a named care co-ordinator • Ensure people with RA have education and support to manage their disease • Offer a comprehensive, holistic, annual review.