Adults with RA should have access to specialist occupational therapy, with periodic review, if they have: difficulties with any of their everyday activities. This will require revision of local protocols in order that step-up protocols may be implemented rather than initial combination therapy. Thereafter it is recommended that patients should have a review appointment after six months to ensure that the target has been maintained and if stable to be reviewed at least on an annual basis. The availability of specialist nurses is often instrumental in supporting these recommendations and service planning should consider the resources required to deliver both monthly monitoring and annual review. Registered in the United Kingdom. There is no specific diagnostic test for rheumatoid arthritis (RA), the diagnosis is clinical. NICE does not recommend a preference for first line therapy [ NICE, 2018a ], however the ACR suggests that methotrexate should be the preferred initial treatment for most people with rheumatoid arthritis [ ACR, 2015 ], and EULAR recommends that methotrexate should be part of the first treatment strategy for people at risk of persistent disease, unless contraindicated [ Combe, 2016 ]. July 2018: NICE has made new recommendations on treat-to-target strategy, initial pharmacological management, symptom control and monitoring. This guideline replaces CG79. NICE Pathways; NICE guidance; Standards and indicators; Evidence search; BNF; BNFC; CKS. This guideline covers diagnosing and managing rheumatoid arthritis. This … The previous guideline did not recommend a specific target other than agreeing a target with the patient. 1 Some clinicians will find it challenging to adhere to these, but they reflect best practice. What has proved challenging for some rheumatologists was the recommendation in the 2009 guideline to follow patients monthly until their target was met. In July 2018, the National Institute for Health and Care Excellence (NICE) published revised guidelines for the management of rheumatoid arthritis (RA) disease in adults. Offer all adults with RA, including those who have achieved the treatment target, an annual review to: assess disease activity and damage, and measure functional ability (using, for example, the Health Assessment Questionnaire [HAQ]), check for the development of comorbidities, such as hypertension, ischaemic heart disease, osteoporosis and depression, assess symptoms that suggest complications, such as vasculitis and disease of the cervical spine, lung or eyes, organise appropriate cross referral within the multidisciplinary team, assess the effect the disease is having on a person’s life, For adults who have maintained the treatment target (remission or low disease activity) for at least 1 year without glucocorticoids, consider cautiously reducing drug doses or stopping drugs in a step-down strategy. The UK’s National Institute for Health and Care Excellence (NICE) has recommended AbbVie’s Rinvoq (upadacitinib) for people with previously treated severe active rheumatoid arthritis (RA). In addition, although the use of ultrasound has expanded in rheumatology as well as other specialties, the role of ultrasound in the management of RA is unclear.5 Following an extensive literature review the conclusion in the guideline was not to recommend ultrasonography for routine monitoring of disease activity in adults with RA. Offer verbal and written information to adults with RA to: improve their understanding of the condition and its management, Adults with RA who wish to know more about their disease and its management should be offered the opportunity to take part in existing educational activities, including self-management programmes, See Algorithm 2 for rheumatoid arthritis management and monitoring, Consider oral non-steroidal anti-inflammatory drugs (NSAIDs, including traditional NSAIDs and cox II selective inhibitors), when control of pain or stiffness is inadequate. The guideline recommends that the rheumatologist should inform those with risk factors of a poor prognosis that they have an increased risk of radiological progression. The early signs of RA of joint pain and swelling usually present in primary care. Last revised in April 2020. Kyburz D et al; physicians of SCQM-RA. London: NICE, 2001. www.nice.org. In patients with newly diagnosed active rheumatoid arthritis, monotherapy with a conventional disease-modifying antirheumatic drug (DMARD), either oral methotrexate, leflunomide, or sulfasalazine, should be given as first-line treatment; hydroxychloroquine sulfate, a weak DMARD, is an alternative in patients with mild rheumatoid arthritis or those with palindromic rheumatism. and rheumatoid arthritis. Although labour intensive, this approach may prove cost effective by reducing the number of patients who need to be prescribed a bDMARD. The guideline also recommended that clinicians should consider making the target remission rather than low disease activity for people with an increased risk of radiological progression (that is, those with positive anti-CCP antibodies or erosions on X-ray at baseline assessment). The guideline is relevant to non-specialist health professionals who are involved in the initial assessment of RA symptoms and ongoing care of people diagnosed with RA. Offer to refer adults with RA for an early specialist surgical opinion if any of the following do not respond to optimal non-surgical management: persistent pain due to joint damage or other identifiable soft tissue cause. Some rheumatologists who have not adopted a treat-to-target strategy may need a change in practice. July 2018. www.nice.org.uk/guidance/ng100 (accessed September 2019). © NICE 2020. In addition, there may be challenges to health professionals in primary and secondary care when explaining risk factors for progression to some patients. (2)Trafford General Hospital, Manchester University NHS Foundation Trust, Manchester M41 5SL, UK … What are the implications of these guidelines for commissioners and providers of services for people with RA? BSR's 'gold standard' clinical guidelines support evidence-based clinical practice in rheumatology. The role of ultrasound in diagnosing rheumatoid arthritis, what do we know? If an adult with RA decides to try complementary therapies, advise them: these approaches should not replace conventional treatment, this should not prejudice the attitudes of members of the multidisciplinary team, or affect the care offered, rapid access to specialist care for flares. Extensive literature review also did not find superiority for initial combination compared with a step up strategy. Although control of synovitis with csDMARD and corticosteroids improves symptoms, some patients require additional analgesia. Reg. In contrast to the previous recommendation, the current guideline therefore recommends initiation with a single csDMARD (either sulfasalazine, methotrexate, or leflunomide) and sequentially adding further drugs in a step-up approach if the target is not met. The quality standards for RA were last published in 2013 but are currently being revised. The National Institute for Clinical Excellence (NICE) clinical practice guidelines, published in February 2009, which address RA and place patients at the centre of care, have been greeted with a broadly positive reaction. Author information: (1)National Guideline Centre, Royal College of Physicians, London NW1 4LE, UK. People should also have rapid access to specialist care if their condition suddenly worsens. This guideline was developed by a multidisciplinary expert panel: Cooper C et al with the support of an educational grant from UCB Pharma Ltd. Features a holistic assessment algorithm and treatment options. Management of RA depends on a multidisciplinary approach and shared care between secondary and primary care. Clinicians would normally be expected to undertake regular audit against these standards, and commissioners might be expected to receive assurance that this is undertaken. In addition, In view of the considerable difference in cost between subcutaneous and oral methotrexate, further research needs to be undertaken to determine whether there is greater efficacy of subcutaneous methotrexate compared with oral therapy. Katherine Laight. Curr Opin Rheumatol 2015;27:183–8. Topics A to Z; Specialities; What's new; About CKS; Journals and databases; Read about our approach to COVID-19. Patients with a DAS28 between 3.2 and 5.1 are often referred to as having moderate disease and at present NICE do not have guidance for this group of patients if they have failed csDMARDs; they are not currently eligible for a bDMARD or tsDAMRD unless they have a DAS28 >5.1. NICE guidance is prepared for the National Health Service in England. Diagnosis and management of rheumatoid arthritis in adults: summary of updated NICE guidance BMJ. Summary; Have I got the right topic? Nat Rev Rheumatol 2013;9:137–8. When positive, anti-cyclic citrullinated peptide (CCP) antibodies and/or radiographic erosions at diagnosis in combination with a raised C-reactive protein (CRP) are indicators of a poor prognosis. Available from: www.nice.org.uk/NG100. Published Guidance; Rheumatoid arthritis in adults: management. However, flares of disease are characteristic of many patients with RA and there should be rapid access to specialist care for flares and this is emphasised in the guideline. It aims to improve quality of life by ensuring that people with rheumatoid arthritis have the right treatment to slow the progression of their condition and control their symptoms. A. Abdominal aortic aneurysm; Abortion care; Accident prevention (see unintentional injuries among under-15s) Acute coronary syndromes: early management; Acute coronary syndromes: Overview This guideline covers diagnosing and managing rheumatoid arthritis. The content on this page is intended for UK healthcare professionals only. The recommendations on NSAIDs replace the rheumatoid arthritis aspects only of NICE’s 2001 technology appraisal on cyclo-oxygenase-2 (COX 2) selective inhibitors.11 All the recommendations (except the last one) in the latest guidance on rheumatoid arthritis are taken from NICE’s 2008 osteoarthritis guideline,16 which updated the guidance on COX 2 selective inhibitors and NSAIDs. People tend to develop RA between 40 and 60 years of age, although it can occur at any age. The committee found very limited evidence for paracetamol, opioids, and tricyclic antidepressants for symptom control in rheumatoid arthritis, so the recommendation for “other analgesics” was removed from the update of this guideline and replaced with a recommendation for NSAIDs alone – to consider oral non-steroidal anti-inflammatory drugs (NSAIDs), including traditional NSAIDs and COX II selective inhibitors, when control of pain or stiffness is inadequate taking account of potential gastrointestinal, liver, and cardio-renal toxicity, and the person’s risk factors, including age and pregnancy. NICE Bites is a monthly prescribing bulletin published by North West Medicines Information centre which summarises key recommendations from NICE guidance. Thereafter, if the patient remains with severe active disease (DAS>5.1) they would be eligible for a bDMARD. An updated review. Research is also needed to identify the best use of corticosteroids in RA, and whether ultrasound can improve management. Consider a tailored strengthening and stretching hand exercise programme for adults with RA with pain and dysfunction of the hands or wrists if: they have been on a stable drug regimen for RA for at least 3 months, The tailored hand exercise programme for adults with RA should be delivered by a practitioner with training and skills in this area, All adults with RA and foot problems should have access to a podiatrist for assessment and periodic review of their foot health needs, Functional insoles and therapeutic footwear should be available for all adults with RA if indicated, Offer psychological interventions (for example, relaxation, stress management and cognitive coping skills), Inform adults with RA who wish to experiment with their diet that there is no strong evidence that their arthritis will benefit. 2018 Aug 3;362:k3015. information about when and how to access specialist care, Consider a review appointment to take place 6 months after achieving treatment target (remission or low disease activity) to ensure that the target has been maintained. Throughout the course of their disease, offer them the opportunity to talk about and agree all aspects of their care, and respect the decisions they make. Several aspects of the guideline have remained unchanged since its publication in 2009. This site is intended for health professionals only! Fast and accurate referral to rheumatology services is important to achieve early remission and prevent or reduce disability.2. The guideline recommends referral in any patient when: Referral should be guided by clinical examination and should not be delayed by waiting for results of any investigations as they may be normal especially in early disease. Recommendations for identifying and managing ‘long-COVID’ in primary care, Commissioned by Intercept Pharma UK and Ireland Ltd. Rheumatoid arthritis (RA) is an inflammatory disease largely affecting synovial joints. If anti-CCP antibodies are present or there are erosions on X-ray: advise the person that they have an increased risk of radiological progression but not necessarily an increased risk of poor function, emphasise the importance of monitoring their condition, and seeking rapid access to specialist care if disease worsens or they have a flare, see Algorithm 1 for referral, diagnosis, and investigations, Treat active RA in adults with the aim of achieving a target of remission or low disease activity if remission cannot be achieved (treat-to-target). Achieving the target may involve trying multiple conventional disease-modifying anti-rheumatic drugs (cDMARDs) and biological DMARDs with different mechanisms of action, one after the other, Consider making the target remission rather than low disease activity for people with an increased risk of radiological progression (presence of anti-CCP antibodies or erosions on X-ray at baseline assessment), In adults with active RA, measure C-reactive protein (CRP) and disease activity (using a composite score such as DAS28) monthly in specialist care until the target of remission or low disease activity is achieved, Explain the risks and benefits of treatment options to adults with RA in ways that can be easily understood. However, although this may have resource implications the recommendation remains that all patients should be reviewed monthly in their rheumatology unit until they are in remission or low disease state. NICE; CKS; Topics A to Z; Rheumatoid arthritis; Diagnosis; Rheumatoid arthritis: Diagnosis of rheumatoid arthritis. Cogora Limited, 140 London Wall, London EC2Y 5DN. Helapet launches new product datasheet look with new online archive. This has proved difficult in managing these patients but, with the reduction in costs of bDMARDs, it is hoped that revised health economic analyses will find that it will be cost effective for those with moderate disease to be treated with biosimilar bDMARDs. We systematically reviewed current guidelines for managing rheumatoid arthritis (RA) to evaluate their range and nature, assess variations in their recommendations and highlight divergence in their perspectives. There are over 400,000 people with rheumatoid arthritis … This site is intended for UK healthcare professionals, Guidelines Live 2020—now available on demand, depression in adults with a chronic physical health problem, Non-alcoholic steatohepatitis: identification, management, and referral pathways, New COVID guidelines focus on long-term effects and vitamin D. Refer for specialist opinion any adult with suspected persistent synovitis of undetermined cause. In February 2009, NICE published the first clinical guideline (CG) on Rheumatoid arthritis in adults: management (CG79), with the aim of improving early detection of rheumatoid arthritis (RA) in primary care and ensuring prompt referral to specialist care. Combination conventional DMARDs compared to biologicals: what is the evidence? Clinical guideline [CG79] Published date: 25 February 2009 Last updated: 09 December 2015. RA typically presents as inflammatory arthritis affecting the small joints of the hands and the feet (usually both sides equally and symmetrically) although any synovial joint can be involved. Disease activity can be measured by various tools, such as the DAS28, which is based on a composite score from clinical assessment of the number of tender joints, swollen joints, global pain, and a biomarker for inflammation (either erythrocyte sedimentation rate (ESR) or CRP). Evidence-based information on rheumatoid arthritis guidelines from hundreds of trustworthy sources for health and social care. Rheumatoid arthritis: Summary Rheumatoid arthritis (RA) is a chronic systemic inflammatory disease. The National Institute for Health and Care Excellence (NICE) has issued a positive Final Appraisal Determination (FAD) recommending upadacitinib, a once-daily oral therapy, for people with previously treated severe active rheumatoid arthritis (RA). Topics A to Z; Specialities; What's new ; About CKS; Journals and databases; Read about our approach to COVID-19. Conventional synthetic disease-modifying anti-rheumatic drugs (csDMARDs) are differentiated from targeted synthetic (ts)DMARDs (such as Janus kinase inhibitors) and biologic (b)DMARDs (including inhibitors of cytokines such as tumour necrosis factor and interleukin-6), which were not within the scope of this guideline. This guideline covers diagnosing and managing rheumatoid arthritis. Type: Guidance Add this result to my export selection Rheumatoid arthritis: When should I suspect rheumatoid arthritis? Overview This guideline covers the recognition, diagnosis and early … NICE CG79 recommended that, once in specialist care, patients received early treatment with disease-modifying anti-rheumatic drugs (DMARDs). The annual review should be a comprehensive evaluation and include an assessment of disease activity and damage and any need for surgery, a measure of functional ability (using, for example, the Health Assessment Questionnaire) and impact on life, a check for the development of comorbidities, such as hypertension, ischaemic heart disease, osteoporosis and depression, an assessment of symptoms that suggest complications such as vasculitis and disease of the cervical spine, lung or eyes, and appropriate cross-referral within the multidisciplinary team. Add filter for National Rheumatoid Arthritis Society - NRAS (35) ... Everything NICE has said on managing rheumatoid arthritis in adults in an interactive flowchart. RA is a chronic, disabling autoimmune disease characterised by synovitis of small and large joints causing swelling, stiffness, pain, and progressive joint destruction. NICE; CKS; Topics A to Z; Rheumatoid arthritis; Management; Rheumatoid arthritis: Management. Commissioners and Trusts are expected to adhere to NICE guidelines and to assure the process through regular audit. Initial pharmacological management is led by specialists. If this does not happen, then providers would be open to censure, for example by the Health Service Ombudsman in the event of a complaint, and may lose their eligibility to bid for provision of specialised services. Refer for specialist opinion any adult with suspected persistent synovitis of undetermined cause. Read about our cookies here.. NICE has published technology appraisal guidance on biological and targeted synthetic DMARDs for RA. Welcome to Guidelines. Sethi MK, O’Dell JR. 11 National Institute for Clinical Excellence. However, the evidence for this approach was re-evaluated and a meta-analysis did not find superiority for any individual drug. Summary; Have I got the right topic? The guideline committee were unable to strengthen the recommendation and advise all patients to receive bridging therapy because of the lack of research evidence. The guideline emphasises the importance of rapid referral to a rheumatologist for any adult with suspected persistent synovitis of undetermined cause independent of investigations including blood tests for acute phase response or rheumatoid factor. Guidance. Lage-Hansen PR et al. 1. Rheumatoid arthritis in adults: management: NICE guideline (NG100). This guideline is the basis of QS33. Approximately 1% of the UK population have RA, and as many as 15% of these people may have severe active disease at any point in time. This guidance has been updated and replaced by NICE guideline NG100. Adults with RA should have access to specialist physiotherapy, with periodic review, to: improve general fitness and encourage regular exercise, learn exercises for enhancing joint flexibility, muscle strength and managing other functional impairments, learn about the short-term pain relief provided by methods such as transcutaneous electrical nerve stimulators (TENS) and wax baths. NICE accepts no responsibility for the use of its content in this product/publication. As soon as possible after establishing a diagnosis of RA: measure anti-CCP antibodies, unless already measured to inform diagnosis, X-ray the hands and feet to establish whether erosions are present, unless X-rays were performed to inform diagnosis, measure functional ability using, for example, the Health Assessment Questionnaire (HAQ), to provide a baseline for assessing the functional response to treatment. NICE Bites No 109 July/August 2018 includes one topic: Rheumatoid arthritis in adults. Rheumatoid arthritis in adults: management. It aims to improve quality of life by ensuring that people with rheumatoid arthritis have the right treatment to slow the progression of their condition and control their symptoms. The guidelines are widely used to define ‘minimum standards of care’ in the UK, so that patients and carers using the National Health Service (NHS) know what they are entitled to receive from healthcare providers. Cohen MD, Keystone EC. New NICE guidelines focus on managing the long-term effects of COVID-19, and vitamin D use in the context of COVID‑19, A clear, concise summary of NICE’s guideline on the care and management of osteoarthritis. People should also have rapid access to specialist care if their condition suddenly worsens. This is in order to emphasise the importance of the patient monitoring their condition and seeking rapid access to specialist care if disease worsens or they have a flare. NICE recommends upadacitinib for severe rheumatoid arthritis. Our guidelines grow out of the collaborative efforts of many members and non-members, specialists and generalists, patients and carers. A brief summary of SIGN's guideline on management of osteoporosis and prevention of fragility fractures, including risk factors and a treatment algorithm. The recommendations and evidence in chapters 7 and 8 have been stood down and replaced. However, they could be encouraged to follow the principles of a Mediterranean diet (more bread, fruit, vegetables and fish; less meat; and replace butter and cheese with products based on vegetable and plant oils), Inform adults with RA who wish to try complementary therapies that although some may provide short-term symptomatic benefit, there is little or no evidence for their long-term efficacy. Rheumatology 2011;50(6):1106–10. Diagnosis and management of rheumatoid arthritis in adults: summary of updated NICE guidance. NICE (National Institute for Health and Clinical Excellence) published rheumatoid arthritis Management Guidelines in 2009 which recommend that in recently diagnosed, active rheumatoid arthritis, combinations of conventional disease modifying anti-rheumatic drugs (DMARDs), along with short-term steroids in some form. This is more challenging than the recommendation in 2009 and could have resource implications as patients might have more treatment and follow up appointments. The previous guideline recommended initial treatment with a combination of two or more csDMARDs including methotrexate. Take account of potential gastrointestinal, liver and cardio-renal toxicity, and the person’s risk factors, including age and pregnancy. NICE publishes evidence-based recommendations for health and care in England (not Wales or Scotland, although they can also be used there). How up-to-date is this topic? It affects roughly three times as many women as men. An annual review was also included in the previous guideline but many rheumatologists have found a comprehensive review to be difficult to deliver. Cox-II inhibitors for the treatment of osteoarthritis. The lowest effective dose for the shortest possible time of NSAIDs was recommended with co-prescription of a proton pump inhibitor and regular review of risk factors for adverse events. When patients with RA have met their target, monitoring patients on DMARDs should be shared between primary and secondary care. The long-term impact of early treatment of rheumatoid arthritis on radiographic progression: a population-based cohort study. National Institute for Health and Care Excellence. [C] For example, paraesthesia, weakness, unsteadiness, reduced power, extensor plantars. In July 2018, the National Institute for Health and Care Excellence (NICE) published revised guidelines for the management of rheumatoid arthritis (RA) disease in adults.1 Some clinicians will find it challenging to adhere to these, but they reflect best practice. Allen A(1), Carville S(1), McKenna F(2); Guideline Development Group. This summary of the NICE rheumatoid arthritis guideline covers: View this summary online at guidelines.co.uk/454370.article, Algorithm 1: Rheumatoid arthritis—referral, diagnosis and investigations, NICE has published a guideline on depression in adults with a chronic physical health problem, Algorithm 2: Rheumatoid arthritis management and monitoring. The recommendations below are from NICE technology appraisal guidance 72. For full details, see the NICE Pathway on rheumatoid arthritis. All rights reserved. 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