Rheumatoid arthritis (RA) is an autoimmune condition that can affect the whole body, but predominantly manifests itself as arthritis of the synovial joints. It affects about 1% of the population in the UK, with females being three times more likely to be affected than males.1 A GP with an average list size of 1800 patients will, therefore, have around 18 individuals with RA. The effects of this chronic disease, and in particular the patterns of joint deformities, are well known. The consequences for patients themselves are just as significant with about a third of patients having to stop work within 2 years of onset.2 Fortunately, over recent years, the management of RA has undergone a dramatic transformation. The days of suppressing disease activity with corticosteroids are rapidly becoming a thing of the past, and instead it is possible to discuss stopping disease activity, and in some cases achieving remission. This latest NICE guideline, The management of rheumatoid arthritis in adults,2 sets the current standards for treating patients and incorporates these new treatments into routine care.
Role of general practitioners
The NICE guideline provides an excellent overview of the current management of RA for primary care, although only a few recommendations are pertinent. For the GP, the most important of the recommendations is to refer urgently if RA is suspected. The guideline moves away from the classic diagnostic rules and instead advises doctors to refer if persistent synovitis is suspected. Urgent referral is indicated if:
- the small joints of the hands or feet are affected
- more then one joint is affected
- there has been a delay of ?3 months between onset of symptoms and seeking medical advice.
Specialists want to see these patients as soon as possible, as aggressive early treatment leads to improved outcomes.3 Unfortunately, synovitis is notoriously difficult to detect, particularly if experience in this area is limited. The guideline offers no other guidance as to when referral should be considered during initial diagnosis. Softer symptoms, which the patient is less likely to mention and that may be more prominent early on in the disease (e.g. flu-like features and loss of function),4 are also not highlighted.
Clinical Guideline 79 supersedes previous NICE guidance on the use of non-steroidal anti-inflammatory drugs (NSAIDs) and in particular cyclo-oxygenase-2 (COX-2) selective inhibitors in RA.5 The advice is concordant with the recent NICE guideline on the management of osteoarthritis: the safest possible medication should be used whenever possible; and anti-inflammatory agents should be prescribed at the lowest effective dose and for the shortest possible period of time. Both of the guidelines recommend the co-prescribing of a proton pump inhibitor with NSAIDs and COX-2 inhibitors.2,6
The importance of co-morbidities in patients with RA, specifically hypertension, ischaemic heart disease, osteoporosis, and depression, is also highlighted. This may be a particular area where GPs can play a leading role, especially with the involvement of NICE in the ongoing development of the quality and outcomes framework. For example, it may be that screening patients for these conditions becomes a routine part of a GP’s workload.
The other recommendations in the NICE guideline on RA are aimed predominantly at secondary care with a particular focus on pharmacological management and monitoring the disease activity. The guideline highlights the importance of a multidisciplinary team, with all members having experience of treating RA. The importance of the nurse specialist, who is responsible for coordinating care, is highlighted. Once treatment is established and the disease is controlled, it is suggested that follow up takes place at locations suitable to the patients themselves. This may mean that more clinics will need to be held in community settings or that GPs acquire a role in long-term follow up.
Ease of implementation
This guideline is going to have significant resource implications for primary care trusts. The intensive treatment regimens will require more follow up in the early stages. Whether or not this will be provided in hospital or devolved to primary care remains to be seen. If the latter is preferred, GPs will need to become more experienced in the prescribing, monitoring, and side-effects of disease-modifying anti-rheumatic drugs (DMARDs). Biological treatment (e.g. adalimumab, etanercept, infliximab) is effective but expensive, and is recommended for use in patients who have failed a trial of two DMARDs and who still have active disease.7 This guidance has been followed in some areas, but not all as there has been, and still is, a significant element of postcode prescribing. Some trusts may experience difficulties implementing this recommendation because of financial implications.
For GPs, the main challenge represented by the NICE guideline will be to try and recognise RA early, although, as already mentioned, it provides little support in this area. It may be that this is an area where local specialists need to liaise with primary care to assist doctors in their decision making.
The new NICE guideline sets the benchmark for care of patients with RA, encouraging all doctors to treat the disease early and aggressively with titration of medication until it is under control. The guideline aims to ensure that care is consistent across the country and that patients can access effective treatment when required. Hopefully, early use of biological therapies will prevent significant joint destruction, and the classic deformities that many healthcare professionals are used to seeing, may become a problem of the past.
- Symmons D, Turner G, Webb R et al. The prevalence of rheumatoid arthritis in the United Kingdom: new estimates for a new century. Rheumatology 2002; 41 (7): 793–800.
- National Institute for Health and Care Excellence. Rheumatoid arthritis: the management of rheumatoid arthritis in adults. Clinical Guideline 79. London: NICE, 2009. Available at: www.nice.org.uk/guidance/CG79
- Emery P. Treatment of rheumatoid arthritis. BMJ 2006; 332 (7534): 152–155.
- Kumar and Clarke. Clinical Medicine, 6th ed. Saunders Ltd, 2005.
- National Institute for Clinical Excellence. Guidance on the use of cyclo-oxygenase (Cox) II selective inhibitors, celecoxib, rofecoxib, meloxicam and etodolac for osteoarthritis and rheumatoid arthritis. Technology Appraisal 27. London: NICE, 2001.
- National Institute for Health and Care Excellence. Osteoarthritis: The care and management of osteoarthritis in adults. Clinical Guideline 59. London: NICE, 2008. Available at: www.nice.org.uk/guidance/CG59
- National Institute for Health and Care Excellence. Adalimumab, etanercept and infliximab for the treatment of rheumatoid arthritis. Technology Appraisal 130. London: NICE, 2007. Available at: www.nice.org.uk/guidance/TA130 G