improvement, or prevention of further deterioration, of joint function, Offer urgent combined medical and surgical management to adults with RA who have suspected or proven septic arthritis (especially in a prosthetic joint). Diagnosis and management of rheumatoid arthritis in adults: summary of updated NICE guidance BMJ. Rheumatol Int 2017;37:179–87. An updated review. There has been a delay of three months or longer between onset of symptoms and seeking medical advice. Refer all people suspected of having RA for specialist assessment. July 2018: NICE has made new recommendations on treat-to-target strategy, initial pharmacological management, symptom control and monitoring. Several aspects of the guideline have remained unchanged since its publication in 2009. Topics A to Z; Specialities; What's new; About CKS; Journals and databases; Read about our approach to COVID-19. Return promptly to the previous DMARD regimen if the treatment target is no longer met, Do not use ultrasound for routine monitoring of disease activity in adults with RA. It is recommended that CCP, CRP and X-rays are arranged at initial diagnosis in secondary care if they were not undertaken before referral. NICE at present does not have a recommendation for those who have not met the target of at least low disease activity and do not have severe active disease; this is currently under review because of the reduction in the cost of some drugs following the introduction of tsDMARDs and biosimilar bDMARDs. NICE also publishes quality standards in the form of statements that are designed for commissioners and providers to identify gaps in service provision and areas for improvement, to facilitate measurement of quality of care and demonstration of high quality care, with the aim to facilitate commissioning of high quality services. The express aim of the Institute is to prevent ill health, to promote and protect good health, to improve the quality of care and services and to adapt and provide health and social care services. (Technical appraisal 27). Type: Guidance Add this result to my export selection Rheumatoid arthritis: When should I suspect rheumatoid arthritis? Rheumatoid arthritis in adults: management. Cohen MD, Keystone EC. In addition, there may be challenges to health professionals in primary and secondary care when explaining risk factors for progression to some patients. Combination conventional DMARDs compared to biologicals: what is the evidence? 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. It typically affects the small joints of the hands and the feet, and usually both sides equally and symmetrically, although any synovial joint can be affected. Refer for specialist opinion any adult with suspected persistent synovitis of undetermined cause. 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. 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. The revised guideline now recommends that patients with active RA are treated with the aim of achieving a target of remission or low disease activity if remission cannot be achieved (treat-to-target). The quality standards for RA were last published in 2013 but are currently being revised. 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. 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. The recommendation to especially target patients with poor prognostic markers will need to be included in new protocols. Author information: (1)National Guideline Centre, Royal College of Physicians, London NW1 4LE, UK. Published by Scottish Intercollegiate Guidelines Network (SIGN), 01 February 2011 (2011) Guideline 123: Management of early rheumatoid arthritis - Full guideline. 1. Registered in the United Kingdom. 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. This … 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. However, rheumatologists should be encouraged to prescribe short term steroids when initiating or changing a DMARD and also for disease flares. Rational therapy in RA: Issues in implementing a treat-to-target approach in RA. Ultrasound scanning of joints is increasing, and the recommendation not to use ultrasound routinely may need to be reflected in the revision of local protocols. Clinical guideline [CG79] Published date: 25 February 2009 Last updated: 09 December 2015. This guideline covers diagnosing and managing rheumatoid arthritis. 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. doi: 10.1136/bmj.k3015. 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. A. Abdominal aortic aneurysm; Abortion care; Accident prevention (see unintentional injuries among under-15s) Acute coronary syndromes: early management; Acute coronary syndromes: London: NICE, 2001. www.nice.org. Nat Rev Rheumatol 2013;9:137–8. 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. All rights reserved. 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). 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. If an adult with RA develops any symptoms or signs that suggest cervical myelopathy: Do not let concerns about the long-term durability of prosthetic joints influence decisions to offer joint replacements to younger adults with RA. Sethi MK, O’Dell JR. For full details, see the NICE Pathway on rheumatoid arthritis. This is surprising to those who consider methotrexate to be superior although this is not supported by current data. The guideline recommendation is to “Consider short term bridging treatment with glucocorticoids (oral, intramuscular, or intra-articular) when starting a new conventional synthetic DMARD.”. Overview This guideline covers the recognition, diagnosis and early … 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. July 2018. www.nice.org.uk/guidance/ng100 (accessed September 2019). This guidance has been updated and replaced by NICE guideline NG100. Published Guidance; Rheumatoid arthritis in adults: management. Welcome to Guidelines. Subject to Notice of rights. The previous guideline recommended initial treatment with a combination of two or more csDMARDs including methotrexate. Cogora Limited, 140 London Wall, London EC2Y 5DN. Once a patient has achieved and maintained their treatment target of remission or low disease activity for at least a year without glucocorticoids, the guideline recommends the rheumatologist should consider cautiously reducing drug doses or stopping drugs in a step-down strategy but to return promptly to the previous DMARD regimen if the treatment target is no longer met. 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. 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. [C] For example, paraesthesia, weakness, unsteadiness, reduced power, extensor plantars. RA is a chronic, disabling autoimmune disease characterised by synovitis of small and large joints causing swelling, stiffness, pain, and progressive joint destruction. 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. When treating symptoms of RA with oral NSAIDs: offer the lowest effective dose for the shortest possible time, review risk factors for adverse events regularly, If a person with RA needs to take low-dose aspirin, healthcare professionals should consider other treatments before adding an NSAID (with a PPI) if pain relief is ineffective or insufficient, Adults with RA should have ongoing access to a multidisciplinary team. NICE publishes evidence-based recommendations for health and care in England (not Wales or Scotland, although they can also be used there). Reg. 2018 Aug 3;362:k3015. The management of RA has evolved in the nine years since the previous NICE guideline on RA was published, with greater emphasis on a treat-to-target strategy rather than specific drug regimens,3 and debate about the merit of initiating treatment with combination drug therapy.4 Technologies such as ultrasound have been increasingly used for diagnosis and monitoring of synovitis where it is unclear from clinical examination.5 These aspects of management were investigated by the Guideline Committee, and recommendations have been updated using new evidence, leading to changes to the recommendations for treatment with conventional synthetic disease modifying anti-rheumatic drugs (csDMARDs), glucocorticoids for bridging treatment, and choice of treatment for symptom control. How up-to-date is this topic? A brief summary of SIGN's guideline on management of osteoporosis and prevention of fragility fractures, including risk factors and a treatment algorithm. Management of RA depends on a multidisciplinary approach and shared care between secondary and primary care. Cox-II inhibitors for the treatment of osteoarthritis. 2147432 cogora.com, Subscribe to Hospital Pharmacy Europe newsletter and magazine, FDA approval for ILUVIEN® in DME strengthens Alimera Sciences in global ophthalmology arena, EMA updates guidance on insomnia medication, Robots revolutionise dispensing in hospitals, Feedback: Automation systems in your hospital, Helapet introduce new, improved 20mm Vented Vial Adapter, User-friendly osteoporosis therapy launched, Recent progress in drug treatments for cancer, Cytostatics and the challenge of documenting stabilities, Boehringer Ingelheim initiates Phase III clinical trial with novel oral agent in advanced breast cancer, Early conversations crucial in management of type 2 diabetes, Rapid referral based on clinical examination alone, Treat to target of remission or low disease activity, csDMARD monotherapy then step up combination, The small joints of the hands or feet are affected. What are the implications of these guidelines for commissioners and providers of services for people with RA? 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. 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. 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 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). Summary; Have I got the right topic? The recommendations and evidence in chapters 7 and 8 have been stood down and replaced. There are over 400,000 people with rheumatoid arthritis … Curr Opin Rheumatol 2015;27:183–8. NICE recommends upadacitinib for severe rheumatoid arthritis. Adults with RA should have access to specialist occupational therapy, with periodic review, if they have: difficulties with any of their everyday activities. Research is also needed to identify the best use of corticosteroids in RA, and whether ultrasound can improve management. Features a holistic assessment algorithm and treatment options. 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. 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. Our guidelines grow out of the collaborative efforts of many members and non-members, specialists and generalists, patients and carers. 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. Read about our cookies here.. Last revised in April 2020. 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 ]. NICE guidance is prepared for the National Health Service in England. Clinicians would normally be expected to undertake regular audit against these standards, and commissioners might be expected to receive assurance that this is undertaken. 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. Refer urgently (even with a normal acute-phase response, negative anti-cyclic citrullinated peptide [CCP] antibodies or rheumatoid factor) if any of the following apply: 1.1. the small joints of the hands or feet a… Diagnosis and management of rheumatoid arthritis in adults: summary of updated NICE guidance. Available from: www.nice.org.uk/NG100. 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. Refer urgently (even with a normal acute-phase response, negative anti-cyclic citrullinated peptide [CCP] antibodies or rheumatoid factor) if any of the following apply: the small joints of the hands or feet are affected, there has been a delay of 3 months or longer between onset of symptoms and seeking medical advice, If the following investigations are ordered in primary care, they should not delay referral for specialist opinion, Offer to carry out a blood test for rheumatoid factor in adults with suspected rheumatoid arthritis (RA) who are found to have synovitis on clinical examination, Consider measuring anti-CCP antibodies in adults with suspected RA if they are negative for rheumatoid factor, X-ray the hands and feet in adults with suspected RA and persistent synovitis. NICE has published technology appraisal guidance on biological and targeted synthetic DMARDs for RA. 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; Management; Rheumatoid arthritis: Management. Although control of synovitis with csDMARD and corticosteroids improves symptoms, some patients require additional analgesia. Extensive literature review also did not find superiority for initial combination compared with a step up strategy. Lage-Hansen PR et al. The previous guideline did not recommend a specific target other than agreeing a target with the patient. An annual review was also included in the previous guideline but many rheumatologists have found a comprehensive review to be difficult to deliver. 1 The decision means that people with severe RA may now benefit from upadacitinib, which is the only treatment to have demonstrated improved … 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. [B] Cosmetic improvements should not be the dominant concern. Definitions of remission or low disease activity vary according to the measure used. NICE Pathways; NICE guidance; Standards and indicators; Evidence search; BNF; BNFC; CKS. Rheumatoid arthritis (RA) is an inflammatory disease largely affecting synovial joints. The guideline committee were unable to strengthen the recommendation and advise all patients to receive bridging therapy because of the lack of research evidence. No. Kyburz D et al; physicians of SCQM-RA. NICE Bites No 109 July/August 2018 includes one topic: Rheumatoid arthritis in adults. 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. It is a systemic disease and so can affect the whole body, including the heart, lungs and eyes. 1 Some clinicians will find it challenging to adhere to these, but they reflect best practice. 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. Evidence-based information on rheumatoid arthritis guidelines from hundreds of trustworthy sources for health and social care. 11 National Institute for Clinical Excellence. 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. Although current evidence suggests that all people with RA should be offered the same management strategy, it is possible that those identified with a risk of poor prognosis should be treated differently. This guideline is the basis of QS33. Commissioners and Trusts are expected to adhere to NICE guidelines and to assure the process through regular audit. Overview This guideline covers diagnosing and managing rheumatoid arthritis. 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. Guidance. NICE accepts no responsibility for the use of its content in this product/publication. This guideline replaces CG79. and rheumatoid arthritis. Recommendations for identifying and managing ‘long-COVID’ in primary care, Commissioned by Intercept Pharma UK and Ireland Ltd. For example, with the DAS28, remission is a score of <2.6 and low disease activity is ≤3.2. Katherine Laight. The long-term impact of early treatment of rheumatoid arthritis on radiographic progression: a population-based cohort study. 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. People should also have rapid access to specialist care if their condition suddenly worsens. Offer to refer adults with any of the following complications for a specialist surgical opinion before damage or deformity becomes irreversible: nerve compression (for example, carpal tunnel syndrome), When surgery is offered to adults with RA, explain that the main. Thereafter, if the patient remains with severe active disease (DAS>5.1) they would be eligible for a bDMARD. Allen A(1), Carville S(1), McKenna F(2); Guideline Development Group. National Institute for Health and Care Excellence. 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 content on this page is intended for UK healthcare professionals only. Last revised in April 2020. The role of ultrasound in diagnosing rheumatoid arthritis, what do we know? 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. Some rheumatologists who have not adopted a treat-to-target strategy may need a change in practice. For guidance on using DMARDs to achieve treatment targets, see recommendation 1.2.1. © NICE 2020. This guideline was developed by a multidisciplinary expert panel: Cooper C et al with the support of an educational grant from UCB Pharma Ltd. 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. It aims to improve quality of 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. 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. BSR's 'gold standard' clinical guidelines support evidence-based clinical practice in rheumatology. 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. The early signs of RA of joint pain and swelling usually present in primary care. Long-Covid ’ in primary care, patients and carers professionals only ; Specialities ; 's! 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