Dr Louise Warburton discusses the new BSR guideline on rheumatoid arthritis, and its shortfalls in primary care
In July 2006, the British Society of Rheumatology (BSR) published a guideline on the management of rheumatoid arthritis (RA) during the first 2 years of the disease.1
The guideline stresses the importance of tight control of the disease, and likens it to diabetes and hypertension, because it is also a disease that needs to be diagnosed and treated early to minimize the development of complications.2 The longer RA goes untreated, the worse the complications are.
It has been shown that patients who wait over 1 year from symptom onset to referral to a rheumatologist have a 73% risk of developing erosive change prior to treatment being initiated.3
Long-term synovitis means more joint damage, and the potential for more joint replacements being required in later life; not to mention a loss of quality of life for the patient.
Model of care
The guideline proposes a 'model of care' for identifying patients early in the course of their disease (within 3 months of the onset of symptoms), and using this 'window of opportunity' to commence disease-modifying anti-rheumatic drugs (DMARDS), which have been shown to slow the progression of the disease.4
Primary care physicians and nurses are encouraged to recognize patients within this 3 month time window, and an algorithm is provided to aid referral.
Diagnosing rheumatoid arthritis
Rheumatoid arthritis is deemed to be present if there is persistent joint inflammation affecting at least three joint areas, including the metacarpophalangeal joints and the metatarsophalangeal joints, and at least 30 minutes of morning stiffness.
Sadly, this 'ideal' patient is a rare beast in general practice. What exactly is 'morning stiffness'? Lots of patients with osteoarthritis complain of feeling stiff. GPs are all familiar with a patient presenting with one inflamed joint and perhaps a past history of other joint inflammation.
Blood tests can be equivocal, and it is, therefore, a real diagnostic challenge to decide whether or not patients have an inflammatory arthropathy. Even if a GP decides that the patient warrants referral, the waiting list to be seen in secondary care is over 13 weeks in some areas.
There are no diagnostic tips offered to help the GP to make an early diagnosis and referral. The guideline talks about disease activity scores (DAS), which most GPs will not be familiar with. It is clear that this new guideline is aimed at secondary care.
A GP with a special interest in rheumatology or musculoskeletal medicine may be able to breech the gap between primary and secondary care, but I feel that there should be better guidelines available to all GPs. The Primary Care Rheumatology Society is currently working on primary care orientated guidelines for its website.5They should be available in the NewYear.
The BSR guideline states that '... education of primary care can improve the effectiveness of early referral. It is recommended that better coordination is established between primary and secondary care in order to facilitate care for patients with RA.' A model of care is proposed where primary care management takes over as the disease becomes established, and only nurse-led annual reviews take place in secondary care.
Which primary care physicians have time to establish anything other than a passing relationship with their local rheumatologist?
Because musculoskeletal medicine has not been included in QOF2, it has been forced into a position of low priority. More resources need to be invested in musculoskeletal medicine in both primary and secondary care. We cannot take on the long-term management of RA in primary care as most GPs just do not have the necessary skills.
Cardiovascular disease risk
The new BSR guideline does stress the importance of cardiovascular disease risk in RA; this is an important area, which is only just being recognized.
Having RA is a cardiovascular risk factor in itself.6 The use of statins has been shown to have an anti-inflammatory effect in RA as well as reducing cholesterol.7 Screening for cardiovascular risk factors in primary care is advocated in all patients with RA.
Lifestyle advice is also encouraged.
However, the guideline does not make it clear when statins should be initiated; for example, at what level of cardiovascular risk, such as Framingham risk.
The BSR guideline presents a care model for RA in an ideal world. It provides some useful algorithms, including one for the management of the hot swollen joint in adults; however, more work is needed to educate GPs on how to recognize the signs of early RA, so that early referral can actually take place.
- Luqmani R, Hennell S, Estrach C et al. British Society for Rheumatology and British Health Professionals in Rheumatology Guideline for the Management of Rheumatoid Arthritis (The first 2 years). Rheumatology (Oxford) 2006; Jul 13: Epub ahead of print.
- Pincus T, Gibofsky A,Weinblatt M et al. Urgent care and tight control of rheumatoid arthritis as in diabetes and hypertension: better treatments but a shortage of rheumatologists. Arthritis Rheum 2002; 46 (4): 851–854.
- Irvine S, Munro R, Porter D et al. Early referral, diagnosis and treatment of rheumatoid arthritis: evidence for changing medical practice. Ann Rheum Dis 1999; 58 (8): 510–513.
- O'Dell J. Therapeutic strategies for rheumatoid arthritis. N Eng J Med 2004; 350 (25): 2591–2602.
- Goodson N,Wiles N, Lunt M et al. Mortality in early inflammatory polyarthritis: cardiovascular mortality is increased in seropositive patients. Arthritis Rheum 2002; 46 (8): 2010–2019.
- McCarey D, Sattar N, McInnes I. Do the pleiotropic effects of statins in the vasculature predict a role in inflammatory diseases? Arthritis Res Ther 2005; 7 (2): 55–61.