Guideline 48 Summary of recommendations

Management of Early Rheumatoid Arthritis
Summary of recommendations

Treatment overview

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

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.

NSAIDs

The lowest NSAID dose compatible with symptom relief should be prescribed.

NSAIDs should be reduced and if possible withdrawn when a good response to DMARDs is achieved.

Simple analgesics should be used in place of NSAIDs if possible and DMARDs should be introduced early to suppress disease activity.
Only one NSAID should be prescribed at a time.
Prescribers should be aware of the many potential drug interactions with NSAIDs and the side effect profiles of different drugs.
NSAIDs should be avoided in patients taking anticoagulants or corticosteroids.

Introduce gastroprotection in RA patients >65 years and in those with a past history of peptic ulcer.

DMARDs

Early DMARD therapy in RA is important to maintain function and reduce later disability.

DMARD therapy should be sustained in inflammatory disease in order to maintain disease suppression.

DMARD choice should take into account patient preference and existing co-morbidity.

Sulphasalazine, methotrexate, IM gold, and pencillamine are equally effective DMARDs.

Sulphasalazine and methotrexate are the current DMARDs of choice due to their more favourable efficacy/toxicity profiles.

Patients should be counselled about the benefits and risks of specific DMARDs, and should be provided with additional written information
Good liaison between primary and secondary care is essential. Rheumatology nurse specialists have an important role in this aspect of care
Monitor for continued efficacy (ESR/CRP, number of tender and swollen joints, duration of morning stiffness, function).
Monitor toxicity using British Society of Rheumatology/local guidelines or manufacturers' data sheet recommendations.
Clear advice about the monitoring of specific DMARDs should be available to the patient, GP and practice nurse.

At present the balance of evidence does not support the routine use of combination DMARD therapy in early RA.

Intra-articular corticosteroids

Intra-articular injections can be used for rapid, and sometimes sustained, symptomatic relief in 'target' joints.
Intra-articular injections to any one joint should not be given more than three times in one year.
When administering intra-articular injections:
use sterile technique
advise patients how to seek help if joint fails to settle after injection
always consider possible septic arthritis in differential diagnosis of mono/oligo flare in RA.

Corticosteroid therapy

Oral corticosteroids are not recommended for routine use, as there is no sustained clinical or functional benefit and there is high risk of toxicity with long term use.

Inform patients of the risks of corticosteroids prior to prescription and issue steroid warning card.
Intramuscular corticosteroid allows control of dose and duration of therapy and may be preferable to oral therapy.
Oral corticosteroids should be withdrawn slowly to avoid rebound flare of symptoms.

The lowest possible dose of corticosteroid should be used for the shortest possible time.

Monitor patients closely for adverse corticosteroid effects. Be alert to the possibility of diabetes, cataract and infection. Inform patients not previously infected of the danger of chicken pox/shingles exposure

Ensure adequate surveillance and prophylaxis of osteoporosis in patients taking oral corticosteroids.

The role of the multidisciplinary team

All patients with early RA should have access to a range of health professionals, including general practitioner, rheumatologist, nurse specialist, physiotherapist, occupational therapist, dietitian, podiatrist, pharmacist, and social worker.

Skilled occupational therapy advice should be available to those experiencing limitations in function.

Resting and working splints can be used to provide pain relief

Patients should be encouraged to undertake simple dynamic exercises.

Podiatry referral should be offered to all patients.

Management of Early Rheumatoid Arthritis Summary of recommendations

Management of Early Rheumatoid Arthritis
Summary of recommendations