3.1 Early initiation of treatment

It is well documented that the function of patients with RA will decline over time.^35,36,37 The goals of treatment, therefore, are symptom control, reduction of joint damage and disability and maintenance or improvement of quality of life. Whilst current therapies seldom achieve remission, they can slow disease progression and thereby reduce functional loss. Evidence level 2+

RA should be treated as early as possible with disease modifying anti-rheumatic drugs (DMARDs) to control symptoms and delay disease progression.

All patients with persistent inflammatory joint disease (>6-8 weeks duration) already receiving simple analgesics and nonsteroidal anti-inflammatory drugs (NSAIDs) should be considered for referral for specialist rheumatology opinion and DMARD therapy, preferably within 12 weeks.

3.2 Multidisciplinary team approach

Effective high quality treatment of early RA is multifaceted and involves the general practitioner (GP), rheumatologist, nurse specialist, physiotherapist, occupational therapist, dietitian, podiatrist, pharmacist and social worker.³⁸ A shared care approach between primary and secondary care physicians,³⁹ facilitated by practice nurses and rheumatology nurse specialists, ensures optimum monitoring of the efficacy and toxicity of drug therapy and the prompt identification of the complications of RA and its treatments.

3.3 Patient education

A common approach to patient education should be adopted by all members of the multidisciplinary team to ensure that patients receive a consistent health message (see Annexes 9, 10 and 11).⁴⁰ Patient education leaflets increase knowledge about the disease.⁴¹ Educational interventions including a psychobehavioural component in addition to providing information appear to have better outcomes in terms of pain relief, joint protection and functional disability, but are labour intensive. ^42,43

Patient led self-management education programmes (see Annex 11 for useful contacts) are increasing in popularity but evidence of their effectiveness is still limited.^44,45 Careful evaluation of these programmes would be required in Scotland if they are to be made available more widely.

Patient education should be undertaken by all members of the multidisciplinary teams in both primary and secondary care.

Patients should be provided with an information leaflet/booklet, and if possible, one-to-one education.

3.4 Assessment of response to treatment

Quantification of disease activity and outcome is important in assessing, comparing and standardising treatment of RA. The American College of Rheumatology (ACR) and the European League against Rheumatism (EULAR) have both devised disease activity scores which use composite measures so that comparisons can be made between different studies. Both scoring systems are detailed in Annex 5.

Clinical measures of response to treatment include:

• patient opinion (global assessment; see Annex 5)
• physician opinion (global assessment)
• extent of synovitis (the number of swollen or tender and both swollen and tender joints)
• duration/severity of stiffness after inactivity
• functional ability (e.g. HAQ score; see Annex 4).

Laboratory measures of response to treatment include:

• acute phase response (ESR, CRP)
• anaemia
• radiological progression.

3.5 Hospital admission

Selected patients may benefit from more intensive hospital-based treatment from the multidisciplinary team. Most studies comparing inpatient therapy with intensive outpatient therapy have demonstrated the superiority of the former.^38,46,47 One study has compared inpatient with day patient multidisciplinary therapy for patients with uncomplicated active RA and has shown these approaches to be clinically equivalent with little difference in economic costs.⁴⁸ However, a proportion of the costs of day patient treatment are borne by the patient and practical limitations such as travelling time and social circumstances make this option unsuitable for some patients. Thus it is essential that specialist inpatient facilities are maintained for selected RA patients.

3.6 Cost of untreated disease

The costs incurred in delayed treatment of RA are considerable. These include:

• Personal costs
  • lost work opportunities
  • decreased leisure activities
  • stress on relationships
• Costs to society
  • loss of working skills of RA individuals
  • loss of contributions to the home
  • the burden of economic cost for care.

Work disability can occur early in the course of RA, especially in those with manual occupations.^5,36 Early intervention through retraining and liaison with the patient's employer will help to keep the patient in work for as long as practical and minimise the economic impact of the disease. The most important predictors of work disability are poorer function at the outset, a poorer education level and older age.³ Many patients stop work in the first year after RA onset, highlighting the need for early and effective intervention if work disability is to be avoided.

Overall, patients in the worst functional quartile experience 2.6 times the personal financial cost of those in the best quartile. The hospital costs of the worst quartile are 6.8 times as high. Patients with poor and declining function from the start experience much higher costs of care overall.^{49, 50} Evidence level 2+