Dr Jo Ledingham, Dr Rikki Abernethy, and Mr Ali Rivett present an overview of British Society for Rheumatology guidelines and explain how they could help primary care
The British Society for Rheumatology (BSR) is a professional, clinically-led society representing healthcare professionals in rheumatology and musculoskeletal services. Our role is to promote excellence in the treatment of people with arthritis and musculoskeletal conditions and to support those people delivering it.
The society has had an active guideline development programme for many years following the establishment in 2003 of the Standards, Audit and Guideline Working Group. The working group has progressively worked on establishing robust methodology for the production of evidence-based guidelines and the BSR is keen to publicise its guidelines more widely, including to other clinical groups such as primary care.
The BSR's guideline development process and examples of previous guidelines were submitted to the NICE accreditation programme in 2012.1 Our process met in full the 25 key domains in the NICE assessment and we gained accreditation in 2013. Our guidelines therefore now display the NICE Accreditation Mark as a sign of the high-quality systems used in their development.
Current BSR guidelines
All the BSR guidelines have been developed for use by specialist rheumatology teams but contain guidance that we believe is relevant to individuals working in other specialties and within primary care. Some guidelines are more obviously relevant to primary care than others but all, even when addressing rare conditions such as vasculitis or specialist treatments such as the biologic therapies, contain information that may prove helpful to staff working in primary care. All current BSR guidelines (including those discussed below) can be accessed at: www.rheumatology.org.uk/resources/guidelines/bsr_guidelines.aspx
Hot and swollen joints in adults
A guideline on the management of the hot swollen joint in adults2 was originally published in 2006 and was produced in conjunction with the British Orthopaedic Association, the British Society of Microbial Chemotherapy, and the Royal College of General Practitioners. The recommendations remain unchanged following a literature review in 2011.
This guideline highlights the importance of prompt specialist review of patients presenting with a new onset of a hot, swollen joint. It summarises the key investigations, which include blood cultures and urgent synovial fluid gram stain, culture, and crystal analysis. The importance of prompt treatment after the key investigations have been done is highlighted, together with guidance on appropriate antibiotic regimens to use if joint sepsis is diagnosed or strongly suspected. This guideline includes a management algorithm.
A guideline on the management of gout3 was published in 2007 and covers the management of both acute and chronic gout, including recommendations on the non-pharmacologic lifestyle approaches to managing gout, such as weight control and advice on diet and alcohol use. The guideline covers the clinical indications and timing for starting urate-lowering therapy, and the need for prophylactic treatment when commencing this therapy to prevent acute flares. This can be with colchicine for up to 6 months or, if colchicine is not tolerated, either non-steroidal anti-inflammatory drugs (NSAIDs) or coxibs for 6 weeks, provided these are not contraindicated. The importance of monitoring urate levels and of titrating medication doses to achieve a target serum urate of <300 is covered. Guidance also covers aspirin use in gout. A management pathway algorithm is published with this guideline and a review of the guideline is in progress (final draft expected 2014/2015), which will include use of febuxostat.
Giant cell arteritis and polymyalgia rheumatica
Two separate guidelines have been published on the management of giant cell arteritis (GCA) and polymyalgia rheumatica (PMR), and reviews of both these guidelines are in progress.
Giant cell arteritis (temporal arteritis)
Published in 2010, the guideline on the management of GCA4 covers the population at risk, the key symptoms linked with the condition, and differential diagnoses to consider. The investigations required as baseline disease activity markers and to exclude alternative diagnoses are highlighted; these include the need for, and timing of, temporal artery biopsy in suspected cases, given the predictive value of a positive result. The management of GCA, which depends on the clinical presenting features, is covered including the need for urgent specialist review. Recommendations are made on steroid treatment, with details about starting doses, reduction regimens, the management of any true relapse, and aspirin therapy.
The guideline on the management of PMR5 was published in 2009 and covers the population at risk, the key symptoms linked with the condition, and differential diagnoses to consider. The minimum data set that should be recorded for patients with PMR is defined and includes the key investigations required as baseline disease activity markers and to exclude alternative diagnoses. Early specialist referral is recommended pre-treatment for atypical features, such as:5
- age <60 years
- symptom onset >2 months rather than acute
- lack of shoulder girdle symptoms
- lack of inflammatory stiffness
- prominent systemic features (e.g. weight loss, night pain, or neurological/GCA features)
- normal or extremely high acute-phase response
- features of other rheumatic diseases.
This is because alternative diagnoses may need to be considered in such cases.
Recommendations made on steroid treatment include:
- no urgent requirement to start steroid therapy before the clinical evaluation is complete for PMR with no GCA features
- an initial daily prednisolone dose of 15 mg for 3 weeks
- the need for prompt review to assess response (a patient-reported global improvement of ≥70% within 1 week of commencing steroids is consistent with a diagnosis of PMR).
Specialist referral is recommended for treatment dilemmas, such as:5
- incomplete, poorly sustained, or non-response to steroids
- inability to reduce steroids
- the need for steroid treatment for longer than 2 years.
This is because alternative diagnoses or addition of immunosuppressive therapy (e.g. methotrexate) need to be considered in such cases. A diagnosis and management algorithm is published with this guideline.5
Two guidelines have been produced on the management of rheumatoid arthritis (RA). The first, the Guideline for the management of rheumatoid arthritis (the first two years),6 published in 2006, focuses on the evidence behind the importance of early diagnosis and initiation of effective treatment for RA, including the role of steroids, disease-modifying antirheumatic drugs (DMARDs), NSAIDs, and analgesics. This guideline also covers non-pharmacologic approaches to management.
The second, Guideline for the management of rheumatoid arthritis (after the first 2 years)7 was published in 2009 and focuses on key clinical features and aspects of treatment that should be monitored once a patient has established disease. It also includes recommendations about the annual review process and cardiovascular risk assessment. Both guidelines were published before NICE guidance on RA8 and fed into the NICE guideline development process.
Guidance on the management of adults with antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis9 may not seem of immediate value to primary care practitioners, but the guideline provides information on the new nomenclature for this group of conditions and on the assessments and investigations that help to identify them. There are recommendations on the treatments that rheumatologists are likely to use to induce and maintain disease remission.
Of more potential relevance to primary care is guidance on the prevention and identification of complications from treatment, including recommendations about:
- more frequent cervical smears
- vaccinations for patients receiving immunosuppression
- cardiovascular and thromboembolic risk assessment
- bone protection.
This guideline was published in April 2014 and replaces a previous guideline published in 2007.
Disease-modifying anti-rheumatic drug (DMARD) therapy
Treatments of most relevance to primary care are probably the conventional disease-modifying anti-rheumatic drugs (DMARDs), as most GPs will be issuing prescriptions for these drugs and will have shared-care pathways in place. The DMARD use and monitoring guidance10 was published in 2008 and provides a summary of key indications for, and contraindications to, the prescription of conventional DMARDs. It also summarises pre-treatment screening and treatment monitoring requirements for these drugs. This guideline is under review and new guidance on monitoring requirements for conventional DMARD monotherapy and combination therapy will be produced in the update (final draft expected 2014/2015).
A number of biologic therapy guidelines have been produced. Although biologic medications are prescribed through specialist rheumatology units, we believe these guidelines contain useful information for staff working in primary care. With the exception of the guideline on eligibility criteria for first biologic agent for adults with rheumatoid arthritis (RA),11 all other guidelines review the safety aspects of these relatively new medications.
Eligibility criteria for first biologic agent
The eligibility criteria for first biologic agent for RA guideline was published in 2010 and was an update of the guideline on anti-tumour necrosis factor (TNF) use in RA published in 2001 and revised in 2005. The 2001 and 2005 eligibility criteria were adopted unchanged by NICE in its original recommendations on anti-TNF use.12,13 The 2010 update assessed the evidence for use in less severe disease.
The most widely prescribed biologic agents are the anti-TNF therapies and the latest guideline on safety aspects of anti-TNF therapy in adults with RA was published in 2010.14 This guideline is an update of the original published in 2001 and its revision in 2005. The guideline focuses on recommendations for screening patients prior to starting therapy, contraindications, and relative contraindications to therapy but also covers complications arising from treatment and actions to take should these complications arise. There are specific sections about:14
- infections (e.g. tuberculosis, hepatitis, HIV, opportunistic infections, chicken pox, food hygiene advice, vaccination advice)
- malignancy and pre-malignant conditions, with particular emphasis on skin malignancies
- cardiac failure
- demyelinating disorders
- autoimmune diseases
- haematological disorders
- advice on pregnancy and breastfeeding.
Guidelines on anti-TNF use have also been produced for psoriatic arthritis (PsA) and ankylosing spondylitis (AS). Guidance on the treatment of PsA with biologics15 was published in 2013 and is an update of the guideline originally published in 2005. It highlights the various presentations of PsA (such as dactylitis and enthesitis) in the process of defining the specific indications for biologic therapies. It also covers the safety aspects of these drugs in PsA.
The prescribing of TNF blockers in adults with AS guidance16 was published in 2004 and covers diagnostic criteria for AS, mechanisms for monitoring disease activity, treatment approaches for the disease (including the evidence for efficacy) and hence clinical indications for the anti-TNF therapies. A review of this guideline is in progress.
Rituximab and tocilizumab
Other biologic therapy guidelines published are on rituximab and tocilizumab. Guidance on the use of rituximab in adults with RA17 was published in 2011 and covers:
- the clinical situations in which the use of rituximab can be considered
- specific safety advice about the use of rituximab, for example on:
- monitoring immunoglobulin levels (because of an increasing risk of immunoparesis and therefore infection with long-term use)
- patients with hepatitis
- progressive multifocal leucoencephalopathy (a rare but serious complication).
The guideline on the use of tocilizumab in adults with RA18 was published in 2014 and primarily covers safety aspects of this newer biologic therapy, in particular on the:
- assessment and management of lipid, neutrophil, and liver function abnormalities
- recognised risk of gastro-intestinal perforation.
A guideline reviewing the safety aspects of all biologics for all rheumatic disease indications is in development (final draft expected 2015/2016), and will update previously published guidelines on the anti-TNF agents, rituximab, and tocilizumab. Guidance will be included on screening patients before initiating treatment and on monitoring patients who are receiving treatment.
New BSR guidelines in development
The BSR seeks recommendations for new guidelines on an annual basis and has commissioned some further new guidelines, currently in development. A new guideline specifically looking at the safety of medications relevant to rheumatology practice during pregnancy and breastfeeding is underway and a final draft is anticipated in late 2014. We consider that this guidance may be of particular importance to primary care practitioners.
Other guidelines in development are on the management of systemic lupus erythematosis (SLE) and scleroderma, and these are expected to reach final draft stages in late 2014/early 2015.
Further detail on all these guidelines can be found on the BSR website at rheumatology.org.uk/resources/guidelines/bsr_guidelines.aspx
- NICE website. NICE accreditation. www.nice.org.uk/About/What-we-do/Accreditation (accessed 11 September 2014).
- Coakley G, Mathews C, Field M et al and on behalf of the British Society for Rheumatology Standards, Guidelines and Audit Working Group. BSR & BHPR, BOA, RCGP and BSAC guidelines for management of the hot swollen joint in adults. Rheumatology 2006; 45 (8): 1039
- Jordan K, Cameron J, Snaith M et al on behalf of the British Society for Rheumatology and British Health Professionals in Rheumatology Standards, Guidelines and Audit Working Group. British Society for Rheumatology and British Health Professionals in Rheumatology Guideline for the Management of Gout. Rheumatology 2007; 46 (8): 1372
- Dasgupta B, Borg F, Hassan N et al on behalf of the BSR and BHPR Standards, Guidelines and Audit Working Group. BSR and BHPR guidelines for the management of giant cell arteritis. Rheumatology 2010; 49 (8): 1594
- Dasgupta B, Borg F, Hassan N et al on behalf of the BSR and BHPR Standards, Guidelines and Audit Working Group. BSR and BHPR guidelines for the management of polymyalgia rheumatica. Rheumatology 2010; 49 (1): 186
- Luqmani R, Hennell S, Estrach C et al on behalf of the British Society for Rheumatology and British Health Professionals in Rheumatology Standards, Guidelines and Audit Working Group. British Society for Rheumatology and British Health Professionals in Rheumatology guideline for the management of rheumatoid arthritis (the first 2 years). Rheumatology 2006; 45 (9): 1167
- Luqmani R, Hennell S, Estrach C et al on behalf of the British Society for Rheumatology and British Health Professionals in Rheumatology Standards. Guidelines and Audit Working Group. British Society for Rheumatology and British Health Professionals in Rheumatology guideline for the management of rheumatoid arthritis (after the first 2 years). Rheumatology 2009; 48 (4): 436
NICE. Rheumatoid arthritis: The management of rheumatoid arthritis in adults. Clinical Guideline 79. NICE, 2009. Available at:
- Ntatsaki E, Carruthers D, Chakravarty K et al on behalf of the BSR and BHPR Standards, Guidelines and Audit Working Group. BSR and BHPR guideline for the management of adults with ANCA-associated vasculitis. Rheumatology 2014; doi: 10.1093/rheumatology/ket445 [Epub ahead of print].
- Chakravarty K, McDonald H, Pullar T et al on behalf of the British Society for Rheumatology, British Health Professionals in Rheumatology Standards, Guidelines and Audit Working Group in consultation with the British Association of Dermatologists. BSR/BHPR guideline for disease-modifying anti-rheumatic drug (DMARD) therapy in consultation with the British Association of Dermatologists. Rheumatology 2008; 47 (6): 924-925.
- Deighton C, Hyrich K, Ding T et al on behalf of BSR Clinical Affairs Committee & Standards, Audit and Guidelines Working Group and the BHPR. BSR and BHPR rheumatoid arthritis guidelines on eligibility criteria for the first biological therapy. Rheumatology 2010; 49 (6): 1197-1199.
- NICE. The clinical effectiveness and cost effectiveness of etanercept and infliximab for rheumatoid arthritis and juvenile poly-articular idiopathic arthritis. Technology Appraisal 36. NICE, 2002.
- NICE. Adalimumab, etanercept and infliximab for the treatment of rheumatoid arthritis. Technology Appraisal 130. NICE, 2007. Available at: www.nice.org.uk/Guidance/TA130
- Ding T, Ledingham J, Luqmani R et al on behalf of the Standards, Audit and Guidelines Working Group of BSR Clinical Affairs Committee and BHPR. BSR and BHPR rheumatoid arthritis guidelines on safety of anti-TNF therapies. Rheumatology 2010; 49 (11): 2217-2219.
- Coates L, Tillett W, Chandler D et al on behalf of BSR Clinical Affairs Committee & Standards, Audit and Guidelines Working Group and the BHPR. The 2012 BSR and BHPR guideline for the treatment of psoriatic arthritis with biologics. Rheumatology 2013; 52 (10): 1754-1757.
- Keat A, Barkham N, Bhalla A et al. BSR guidelines for prescribing TNF-α blockers in adults with ankylosing spondylitis. Report of a working party of the British Society for Rheumatology. Rheumatology 2005; 44 (7): 939-947.
- Bukhari M, Abernethy R, Deighton C et al on behalf of the BSR and BHPR Standards, Guidelines and Audit Working Group. BSR and BHPR guidelines on the use of rituximab in rheumatoid arthritis. Rheumatology 2011; 50 (12): 2311-2313.
- Malaviya A, Ledingham J, Bloxham J et al on behalf of the BSR Clinical Affairs Committee & Standards, Audit and Guidelines Working Group and the BHPR. The 2013 BSR and BHPR guideline for the use of intravenous tocilizumab in the treatment of adult patients with rheumatoid arthritis. Rheumatology 2014; 53 (7): 1344-1346.