Dr Gillian Hosie describes the PCR's new evidence-based management protocol which aims to improve the long-term prognosis in rheumatoid arthritis
Rheumatoid arthritis (RA) affects around 1% of the population, with three times as many females as males affected. The clinical course of RA can vary: some patients have only mild disease, while others have serious disease leading to progressive joint destruction with the development of deformity. The latter group suffer increasing pain and stiffness together with a decrease in their functional capacity.
RA may also affect parts of the body other than joints and can give rise to rheumatoid nodules and vasculitis, and pulmonary, cardiac, ophthalmological, neurological and skin complications. There is also evidence that patients with RA suffer premature mortality.1
As well as suffering physical symptoms, patients with RA are also at risk of loss of independence, loss of work opportunities and problems with social interaction, because of limited mobility and dexterity together with systemic symptoms.2
The economic costs of RA are high and include the costs of drugs and other therapies, costs of care, and costs to both patients themselves and to society at large through loss of work.3
There is now increasing evidence that early and sustained treatment with disease-modifying antirheumatic drugs (DMARDs) leads to less joint destruction and a better prognosis. It is important that GPs recognise this fact and take appropriate steps to refer all RA patients to a rheumatologist as early as possible 'or assessment, with a view to starting DMARD therapy.
The management of RA, however, is not solely drug based, but should involve a holistic approach, which is best provided by a multidisciplinary team.
The Primary Care Rheumatology Society (PCR) has developed a management protocol (Figures 1 & 2, below) to help GPs diagnose RA at an early stage, and to encourage them to refer all RA patients as early as possible for consideration of DMARDs and other therapy to try to improve their long-term prognosis.
|Figure 1: Front of the PCR protocol for early referral of patients with rheumatoid arthritis|
|Figure 2: Reverse of the PCR protocol for early referral of patients with rheumatoid arthiritis|
|Relief of symptoms|
|Preservation of function|
|Prevention of structural damage and deformity|
|Maintenance of patient's normal lifestyle|
These are the goals we would aim to achieve in all patients with RA. Joint damage appears to occur early in the course of the disease and we must try to use the so-called 'window of opportunity' to reduce long-term damage and fulfil these goals.
Obviously none of the above can happen until the diagnosis is made. RA is often difficult to diagnose in the early stages of the condition, as symptoms and signs may be intermittent and variable. There is no specific diagnostic test for RA. Diagnosis is made on history and clinical examination and not on laboratory tests, although these may help to support a diagnosis.
In 1987 the American Rheumatism Association produced criteria for the diagnosis of RA4 (Table 1, below), but these are really only for use in a clinical trials situation. At least four of the seven criteria need to be present for a diagnosis of RA under these criteria.
Many patients with RA will not meet these criteria, especially in the early stages, and if we were to wait, for example, until X-ray changes were present, then joint damage would already have taken place.
|Table 1: American Rheumatism Association 1987 revised criteria for the diagnosis of rheumatoid arthritis|
|Morning stiffness of at least one hour, lasting 6 weeks or more|
|Arthritis in at least three joint areas with swelling or exudation, lasting 6 weeks or more|
|Arthritis of hand joints – wrists, metacarpophalangeal (MCP) joints or proximal interphalangeal (PIP) joints – lasting 6 weeks or more|
|Symmetrical arthritis, lasting 6 weeks or more|
|Positive rheumatoid factor|
Patients with RA tend to complain of painful joints, stiffness lasting more than one hour, especially in the mornings, and general and systemic symptoms such as tiredness, weight loss, loss of appetite, night sweats and poor sleeping pattern.
The pattern of affected joints almost always includes hand joints, especially MCP and PIP joints, and the pattern of distribution is usually symmetrical. Wrists and feet are also often involved at an early stage.
The single most important diagnostic sign is synovitis. Synovitis gives rise to a soft swelling around the joints, often described as 'boggy' in contrast to the hard bony swelling of osteoarthritis. Most patients with RA present in this way, although a few may present at the start with a monoarthritis and some with symptoms similar to those of polymyalgia rheumatica.
A number of other conditions can confuse a diagnosis of RA (see Table 2, below).
|Table 2: Differential diagnosis of rheumatoid arthritis|
Other inflammatory conditions, e.g. postviral arthritis
Non-inflammatory conditions, e.g. osteoarthritis
Connective tissue disorders, e.g. systemic lupus erythematosus
Other conditions, e.g. septic arthritis
As already mentioned, there is no specific diagnostic test for RA. If RA is suspected, it is worth checking markers of inflammation such as erythrocyte sedimentation rate (ESR), plasma viscosity and C-reactive protein (CRP), although these are often normal in the early stages. A full blood count (FBC) may show a normochromic and normocytic anaemia.
Rheumatoid factor is worth checking, although it is often not raised in early disease and both false positives and false negatives may occur. An initial high titre of rheumatoid factor is a poor prognostic sign.
If a diagnosis of RA is suspected, the patient should be treated initially with non-steroidal anti-inflammatory drugs (NSAIDs). A good response to NSAIDs does not mean, however, that the condition is under control, but rather that an inflammatory condition is present, suggesting that a DMARD may be required.
Early DMARD therapy has been shown in several studies to be beneficial in reducing later disability and maintaining function.5-7 There is also some evidence that patients respond better to DMARDs in the early stages of disease.8
It is therefore important that patients suspected of having RA are referred as soon as possible for confirmation of the diagnosis and implementation of DMARD therapy. Early referral will also help patients to access the benefits of the multidisciplinary team for education, support and other relevant therapies.
There are often long waiting lists to see consultant rheumatologists. Most rheumatologists triage their referrals to prioritise patients suspected of having inflammatory arthritis, but it can sometimes be very difficult to select patients who need to be seen early from the information given in the referral letter.
One way of resolving this difficulty might be to create a pro-forma referral form for patients suspected of having RA. This referral form would encourage the referring doctor to provide relevant information which would help the rheumatologist to prioritise the referral as appropriate.
Some GPs may consider this patronising, but even the best GP referral letters may at times miss out some important information. Often referral letters explain the patient's signs and symptoms but fail to mention how the patient is coping with his/her disability.
Several areas around the country are using standard referral forms for a number of different conditions. This format could easily be used to facilitate referrals of patients suspected of having RA, and such forms could be developed locally with input from both primary and secondary care.
Relevant information on these forms should include:
|Patient and GP details|
|Symptoms and signs, including synovitis|
|Investigations and results|
Under 'symptoms and signs' it would be useful to list pain, swelling and stiffness or deformity of any affected joint areas, particular the hands and feet, with space for other symptoms and signs if required. It is particularly important to indicate whether synovitis is present.
Results of investigations already performed, such as X-rays of the hands and feet, FBC, ESR, CRP, rheumatoid factor, and any other appropriate investigation should be included.
All co-morbidities should be mentioned, together with relevant drug therapy. It is also important to document any drugs already used for joint symptoms.
Finally, it would be useful to give an idea of the patient's pain, disability, social circumstances, and how he/she is coping with the problem.
Many more things could be included, but it is probably sensible to limit it to those felt to be most useful and which would fit on one page.
Some doctors may feel that a referral form such as this should be used as an adjunct rather than the complete referral, and may wish to include a letter with their referral form to give more information. The main purpose of the suggested referral form is to prompt GPs to send sufficient relevant information for the rheumatologist to prioritise referrals.
Patients should be referred as soon as the diagnosis of RA is suspected, preferably within 6–8 weeks from presentation. If there is any doubt about the diagnosis it is better to refer rather than wait for a definite diagnosis as valuable time may be lost. Remember that referral does not mean loss of input into the patient's management as most areas operate a shared care system.
Table 3 summarises the important points to bear in mind when managing patients with RA.
Table 3: Practice points
|Early DMARD therapy reduces long-term damage|
|Refer early for consideration of DMARD therapy|
|Management of RA should be holistic, not solely drug based|
|Consider using a standard referral form|
|X-rays are likely to be normal in the early stages of disease|
Rheumatoid factor may be negative
A good response to NSAIDs supports a diagnosis of RA rather than a cure of the problem
A number of different drugs are used as DMARDs and prescribing information for these, including dosage, side-effects and monitoring requirements, is included with the management protocol.
This management protocol for RA was put together by a group of PCR Society Steering Committee members with input from a consultant rheumatologist, an expert physiotherapist and an experienced rheumatology specialist nursing sister. The resulting document represents the current and independent views of the PCR Society.
Copies of the management protocol and DMARD prescribing information are available from the Primary Care Rheumatology Society, PO Box 42, Northallerton, N. Yorkshire DL7 8YG.
- Pincus T. Rheumatoid arthritis: a medical emergency? Scand J Rheumatol 1994; 23 (Suppl 100): 21-30.
- Fex E, Larsson B-M,Nived K, Eberhardt K. Effect of rheumatoid arthritis on work status and social and leisure time activities in patients followed eight years from onset. J Rheumatol 1998; 25: 44-50.
- Yelin E, Wanke LE. An assessment of the annual and long term direct costs of rheumatoid arthritis. The impact of poor function and functional decline. Arthritis Rheum 1999; 42: 1209-18.
- Arnett FC, Edworthy SM, Bloch DA et al. The American Rheumatism Association 1987 revised criteria for the classification of rheumatoid arthritis. Arthritis Rheum 1988; 31: 315-24.
- Munro R, Hampson R, McEntegart A, Thomson EA, Madhok R, Capell H. Improved functional outcome in patients with early rheumatoid arthritis treated with intramuscular gold: results of a five year prospective study. Ann Rheum Dis 1998; 57: 88-93.
- Egsmose C, Lund B, Borg G, et al. Patients with rheumatoid arthritis benefit from early 2nd line therapy: 5-year follow-up of a prospective double blind placebo-controlled study. J Rheumatol 1995; 22: 2208-13.
- Van der Heijde A, Jacobs JWG, Bijlsma JWJ et al. The effectiveness of early treatment with 'second-line' antirheumatic drugs. A randomised controlled trial. Ann Intern Med 1996; 124(8): 699-707.
- Anderson J, Wells G, Verhoeven AC, Felson DT. Factors predicting response to treatment in rheumatoid arthritis: the importance of disease duration. Arthritis Rheum 2000; 43: 22-9.