1.1 Background

Rheumatoid arthritis (RA) affects approximately 1% of the population and is more common in women than in men. The course of RA is variable and unpredictable but for a significant number of patients it is a severe disease resulting in persistent pain and stiffness, progressive joint destruction, functional decline and premature mortality.^{1, 2, 3} Equally important to affected individuals is the potential loss of social and financial independence.⁴

The disease also exerts a considerable burden on society in terms of direct (e.g. medical care) and indirect costs (e.g. effects on the individual's ability to work, see section 3.6).^{5, 6}

1.2 The need for a guideline

The traditional management of RA, the 'treatment pyramid', begins with mild, mainly symptomatic measures and defers the use of disease modifying drugs until the disease has progressed further. However, increasing recognition that, for many patients, RA is not a benign condition with a good prognosis has prompted a re-evaluation of therapeutic strategies and the clinical effectiveness of the traditional approach has been widely challenged.^{7, 8, 9} It has been shown that erosive change, leading to joint destruction, often occurs in early disease ^{10, 11, 12, 13, 14} and that early loss of function may be irreversible. In addition, evidence is now accumulating that early more aggressive intervention can improve longer term disease outcome.¹⁵ There is therefore a need for an evidence-based guideline for the management of early RA.

1.3 remit

This guideline addresses diagnosis of early RA, its pharmacological treatment, and the role of the multidisciplinary team in improving care of the RA patient. It is hoped that the guideline will inform standards for practice for rheumatologists, general practitioners (GPs), rheumatology nurse specialists, physiotherapists, occupational therapists, dietitians, podiatrists and pharmacists.

At present there is no formal definition of 'early RA'. It is defined in this guideline as disease duration of <5 years from onset of symptoms.

The guideline does not cover:

• Treatment of co-morbidity (e.g. anaemia, osteoporosis)
• Complications of drug therapy and their management
• Treatment of extra-articular disease (e.g. vasculitis, ocular complications, amyloid)
• Surgical intervention
• Management of children with arthritis.

1.4 Grading of recommendations

This guideline introduces for the first time a revised system for grading guideline recommendations. A key to the new grading system is provided on the inside front cover. Further information is available on the SIGN website.