Rheumatoid arthritis (RA) affects approximately 1% of the population. It can occur at any age, and more commonly affects women than men.
The course of RA is variable and unpredictable, but for a significant number of those affected it is a severe, progressive disease resulting in persistent pain and stiffness, joint destruction, functional decline and premature mortality.1-3
The impact of a diagnosis of RA on an individual can be immense. In addition to physical problems, many suffer lost work opportunities, depression,1 stress on relationships and decreased leisure activities. The implications for society include the economic cost of care.4-6
Implicit, therefore, in the management of RA is the need for a holistic approach to patient care with access to a multidisciplinary team, including medical (GP, rheumatologist), nursing (practice nurse, rheumatology nurse specialist), professions allied to medicine (physiotherapy, occupational therapy, podiatry, dietitian), and social worker.7-8
Why was a guideline needed?
Increasing recognition that, for many patients, RA is a severe progressive disorder with a poor outcome has prompted a re-evaluation of the traditional 'treatment pyramid'. This begins with mild, mainly symptomatic measures and defers the use of disease-modifying antirheumatic drugs (DMARDs) until the disease has progressed.
However, studies have shown that bony erosions, leading to joint destruction, often occur in early disease,9-13 and that early loss of function may be irreversible. Evidence is also accumulating that early, more aggressive intervention can improve longer-term disease outcome.14
Accordingly, the clinical effectiveness of the traditional treatment pathway has been widely challenged.15–17
It seemed an appropriate time, therefore, for the Scottish Intercollegiate Guidelines Network (SIGN) to consider an evidence-based approach to the management of early RA.18
How robust is the evidence?
The management of early RA guideline development group comprised 19 individuals, including representatives from the range of health professionals usually involved in the care of patients with early RA in routine clinical practice.
The group therefore reflected the multidisiciplinary team. As well as rheumatologists, GPs, nurses and the professions allied to medicine, the group also included two patient representatives. These individuals are an important part of any guideline team, as they may bring a different perspective on healthcare issues.
Guideline development group
All SIGN guidelines are developed in a standardised, highly structured way.19 The evidence base for the early RA guideline was developed after a systematic literature search devised by the SIGN information officer in collaboration with the members of the group.
To optimise the quality of the data, mainly systematic reviews, meta-analyses, randomised controlled trials and longitudinal studies were considered. Searches were carried out on the Cochrane Library, Medline, Embase and Pascal, with a sub-search looking at the Allied & Alternative Medicine and Mantis databases. The formal search was supplemented by additional material located by group members.
The evidence base was then critically appraised using SIGN methodology,19 by the development team working in small groups.
The level of evidence allocated to a study (Table 1, below) influences the grade of recommendation that can be made about a particular aspect of disease management.
The early RA guideline introduces a revised system for grading guideline recommendations, as shown in Table 1. Details can be found on the inside front cover of the guidelines18 or on the SIGN website: www.sign.ac.uk
Development of the guideline
Within the guideline group, each member represents both their geographical area and their profession. However, they are also expected to consult with other colleagues within their discipline to ensure the widest possible range of views.
To facilitate wider consultation, a national meeting is held for all interested health professionals when the guideline is at draft stage. This allows further exchange of views and amendment of the guideline if necessary.
The revised draft is then sent out to independent expert peer reviewers who are representative of the disciplines included in the guideline. Comments received are considered before the final draft is prepared.
Gaps in the evidence
The group was acutely aware that lack of evidence does not necessarily mean lack of efficacy and there were areas where good evidence simply was not available, highlighting the need for new research initiatives. Until such new evidence becomes available, recommended best practice, based on the clinical experience of the guideline group, has been included as a 'Good practice point' in those areas where evidence is sparse.
Improving patient care
The primary aim of the guideline is to improve the clinical care of patients with early RA. Key points in both diagnosis and treatment are summarised on the Quick Reference Guide (see Figures 1 & 2, below) included with all copies of the guideline and on the SIGN website.
|Figures 1&2: Quick Reference Guide|
Early diagnosis and referral
Early diagnosis of RA is a prerequisite for early treatment but is not always easy. Key features of both the clinical history and examination are included in the guideline (see Figure 1, above).
All patients with persisting inflammatory joint disease (of >6–8 weeks duration) who are already receiving simple analgesia and nonsteroidal anti-inflammatory drugs (NSAIDs) should be considered for specialist rheumatology opinion and DMARD therapy, preferably within 12 weeks.
Early and sustained use of DMARDs
The evidence shows that RA should be treated as early as possible with DMARDs to control symptoms, delay disease progression and reduce later disability.20–24
To be effective, DMARD therapy needs to be sustained, often over long periods, to maintain disease suppression.25,26
DMARDs in current use are discussed, both in terms of their efficacy and toxicity, in the guideline. At present, however, the evidence does not support the routine use of combination DMARD therapy in early RA.27
Targeted immunotherapy is also briefly discussed, although its place in the treatment of early RA at present is unclear.
Effective and and safe use of NSAIDs and corticosteroids
These drugs are among those most widely used in RA. Despite this, avoidable adverse effects still occur and the guideline hope to highlight ways in which these can be reduced.
NSAIDs provide symptomatic relief of pain and stiffness without influencing the course of RA. To minimise adverse effects (e.g. peptic ulcer, renal impairment), the lowest NSAID dose compatible with symptom relief should be prescribed, and should be reviewed when a good response to DMARD therapy is achieved.
Gastro-protection should be considered in patients aged >65 years and in those with a history of peptic ulcer.28,29
The evidence does not support the routine use of oral corticosteroids as there is no sustained clinical or functional benefit, but there is a high risk of cumulative toxicity with time.
Intra-articular steroid injections can be used for rapid symptomatic relief in 'target' joints.
The multidisciplinary team
The impact of the team approach can be difficult to quantify, but studies do show increased benefit to patients.7
Simple dynamic exercise has been shown to be safe and effective, while skilled occupational therapy and podiatry advice can be invaluable to those experiencing limitations in function and mobility.
Information about both RA and its treatment needs to be provided to patients in an accessible and relevant way. This usually involves all members of the multidisciplinary team, and ideally includes both one-to-one education and written material.30, 31
In addition, many individuals find patient-led support and self-management groups helpful.32
Promoting best practice
Best clinical practice is only as good as the evidence base supporting it. SIGN guidelines serve to indicate the strength of evidence supporting particular interventions and, importantly, to highlight those areas where little or no evidence exists.
The guideline development group hopes to promote best practice in a number of crucial areas, including:
- Prompt diagnosis of RA
- Early and sustained use of DMARDs
- Effective and safe use of NSAIDS and corticosteroids
- Involvement of the multidisciplinary team at an early stage
- The provision of adequate and accessible patient information.
However, despite the numbers of affected individuals and the costs, both personal and to society, musculoskeletal disease is not at present a priority area for the NHS in Scotland. Therefore, to be fully effective, the SIGN guidelines on the management of early RA need to be actively implemented at local level. This requires good liaison and cooperation between members of the multidisciplinary team in both primary and secondary care.
We hope this is something that can be achieved to improve the quality of care we provide to our patients.
- Copies of Management of Early Rheumatoid Arthritis can be obtained from SIGN, Royal College of Physicians, 9 Queen Street, Edinburgh EH2 1JQ (tel 0131 225 7324) or can be downloaded from the website at www.sign.ac.uk
- Wolfe F, Zwillich SH. The long-term outcomes of rheumatoid arthritis: a 23-year prospective longitudinal study of total joint replacement and its predictors in 1600 patients with rheumatoid arthritis. Arth Rheum 1998; 41: 1072-82.
- Pincus T. Rheumatoid arthritis: a medical emergency? Scand J Rheumatol 1994; 100 (Suppl); 21-30.
- Wolfe F. The natural history of rheumatoid arthritis. J Rheumatol 1996: 44 (Suppl): 13-22.
- Young A, Dixey J, Cox N et al. How does functional disability in early rheumatoid arthritis (RA) affect patients and their lives? Results of 5 years of follow-up in 732 patients from the Early RA Study (ERAS). Rheumatology 2000; 39: 603-11.
- Jantti J, Aho K, Kaarela K, Kautiainen H. Work disability in an inception cohort of patients with seropositive rheumatoid arthritis; a 20 year study. Rheumatology 1999; 38: 1138-41.
- Cooper NJ. Economic burden of rheumatoid arthritis: a systemic review. Rheumatology 2000; 39: 28-33.
- Vliet Vlieland TP, Breedveld EC, Hazes JM. The two-year follow-up of a randomized comparison of inpatient multidisciplinary team care and routine outpatient care for active rheumatoid arthritis. Br J Rheumatol 1997; 36: 82-5.
- Pullar T, Hunter JA, Capell HA. Gold and penicillamine therapy: is shared care with general practitioners effective and safe? Rheumatol Rehab 1982; 21; 139-44.
- Brook A, Corbett M. Radiographic changes in early rheumatoid disease. Ann Rheum Dis 1977; 36: 71-3.
- Fuchs HA, Kaye JJ, Callahan LF et al. Evidence of significant radiographic damage in rheumatoid arthritis within the first 2 years of disease. J Rheumatol 1989; 16: 585-91.
- Kaarela K, Kautiainen H. Continuous progression of radiological destruction in seropositive rheumatoid arthritis. J Rheumatol 1997; 24: 1285-7.
- Graudal NA, Jurik AG, de Carvalho A, Graudal HK. Radiographic progression in rheumatoid arthritis: a long-term prospective study of 109 patients. Arth Rheum 1998; 41: 1470-80.
- Drossaers-Bakker KW, de Buck M, van Zeben D et al. Long-term course and outcome of functional capacity in rheumatoid arthritis: the effect of disease activity and radiologic damage over time. Arth Rheum 1999; 42: 1854-60.
- Symmons DP, Jones MA, Scott DL, Prior P. Long-term mortality outcome in patients with rheumatoid arthritis: early presenters continue to do well. J Rheumatol 1998; 25:1072-77.
- Emery P. The Roche Rheumatology Prize Lecture. The optimal management of early rheumatoid disease: the key to preventing disability. Br J Rheumatol 1994: 33: 765-8.
- Emery P. Therapeutic approaches for early rheumatoid arthritis. How early? How aggressive? Br J Rheumatol l995; 34(Suppl 2): 87-90.
- Machold KP, Eberl G, Leeb BF et al. Early arthritis therapy: rationale and current approach. J Rheumatol 1998; 53(Suppl): 13-19.
- Scottish Intercollegiate Guidelines Network. Management of Early Rheumatoid Arthritis. Edinburgh: SIGN, 2000; No 48.
- Scottish Intercollegiate Guidelines Network. An Introduction to SIGN Methodology for the Development of Evidence-based Clinical Guidelines. Edinburgh: SIGN, 1999; No.39.
- Munro R, Hampson R, McEntegart A et al. 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 JW, Bijlsma JW et al. The effectiveness of early treatment with 'second line' antirheumatic drugs. A randomized, controlled trial. Ann Intern Med 1996; 124: 699-707.
- Taskonas E, Fitzgerald AA, Fitzcharles MA et al. Consequences of delayed therapy with second-line agents in rheumatoid arthritis: a 3-year follow-up on the hydroxychloroquine in early rheumatoid arthritis (HERA) study. J Rheumatol 2000; 27: 623-9.
- van Jaarsveld CH, Jacobs JW, van der Veen MJ et al. Aggressive treatment in early rheumatoid arthritis: a randamised controlled trial. On behalf of the Rheumatic Research Foundation Utrecht, The Netherlands. Ann Rheum Dis 2000; 59: 468-77.
- ten Wolde S, Breedveld FC, Hermans J et al. Randomised placebo-controlled study of stopping second-line drugs in rheumatoid arthritis. Lancet 1996; 347: 347-52.
- Gotzsche PC, Hansen M, Stoltenberg M et al. Randomized, placebo-controlled trial of withdrawal of slow-acting antirheumatic drugs and of observer bias in rheumatoid arthritis. Scand J Rheumatol 1996; 25: 194-9.
- Felson DT, Anderson JJ, Meenan RF. The efficacy and toxicity of combination therapy in rheumatoid arthritis. A meta-analysis. Arth Rheum 1994; 37:1487-91.
- Hawkey CJ, Karrasch JA, Szczepanski L et al. Omeprazole compared with misoprostol for ulcers associated with nonsteroidal anti-inflammatory drugs. Omeprazole versus Misoprostol for NSAID-induced Ulcer Management (OMNIUM) Study Group. N Engl J Med 1998; 338: 727-34.
- Silverstein FE, Graham DY, Senior JR et al. Misoprostol reduces serious gastrointestinal complications in patients with rheumatoid arthritis receiving nonsteroidal anti-inflammatory drugs. A randomized, double-blind trial. Ann Intern Med 1995; 123: 241-9.
- Holman HR, Lorig KR. Patient education: essential to good health care for patients with chronic arthritis. Arth Rheum 1997; 40: 1371-3.
- Barlow JH, Weight CC. Knowledge in patients with rheumatoid arthritis: a longer term follow-up of a randomized controlled study of patient education leaflets. Br J Rheumatol 1998; 37: 373-6.
- Lorig KR, Mazonson PD, Holman HR. Evidence suggesting that health education for self-management in patients with chronic arthritis has sustained health benefits while reducing health care costs. Arth Rheum 1993; 36: 439-46.