Rheumatoid arthritis (RA) affects 1–2% of the population.1 It is a devastating disease, with drastic consequences for most individuals, for example cardiovascular risks, an increased likelihood of work instability, and disability.
Long-term outcome studies show that a substantial number of RA patients are unlikely to be able to work at 5 years after onset of the disease.2 Premature death from cardiovascular disease (CVD), approximately 15 years earlier than would occur in otherwise healthy adults, is likely.3
Rheumatoid arthritis mainly affects the middle aged and elderly populations, but may occur at younger ages.1Traditional therapies for RA have been revolutionized over the past 25 years by the more aggressive use of disease modifying anti-rheumatic drugs (DMARDs) and the introduction of biological therapies.4,5 It is no longer acceptable for patients with RA to be managed with minimal or no intervention so that their joints are allowed to deteriorate progressively. If a diagnosis is made early on in the disease course, interventions can be started right away and may, therefore, result in a considerable reduction in disease morbidity, late mortality, and functional deterioration.6
The British Society of Rheumatology (BSR) has developed a guideline for the early management of RA, so that patients can receive prompt and adequate attention to minimize the disease burden.7 Key points for GPs and purchasers have been summarized in Tables 1 and 2, respectively.
Management of RA patients
In order to provide comprehensive care for all patients with RA, it is essential that there is good communication between primary and secondary care so that an early diagnosis can be made.7 The presence of pain or swelling in at least three joint areas, persisting over a period of 3 weeks and associated with morning stiffness of at least 30 minutes duration, should prompt rapid referral.7 Early referral is very important when there is involvement of the metacarpophalangeal or metatarsophalangeal joints in the hands and feet.
Typically, referral would be to the rheumatology department in a local hospital. A team approach is essential for dealing with all aspects of RA, and the support provided by hospital care remains pivotal in the initial few years after diagnosis.
The GP plays an important role in liaising with the secondary care team and encouraging all the healthcare professionals to work together to provide seamless care for their patients.7 As the disease becomes better controlled attention should be turned to the long-term aspects of RA, including CVD risks. GPs can be heavily involved in managing CVD effects of RA on the patient, which are similar to those seen in type 2 diabetes.8
Once a patient is established on effective DMARD therapy, either alone or in combination, it is important that the treatment course is followed so that the patient continues to respond to the treatment. Typical single therapies are methotrexate in doses of up to 25 mg/week; sulfasalazine in doses of up to 40 mg/kg/day; leflunomide in doses of 10–20 mg/day.
Examples of successful combination therapies include lower doses of methotrexate (10–15 mg/week) together with sulfasalazine (1–2 mg/day) and hydroxychloroquine (200–400 mg/day), or combinations of leflunomide and methotrexate. The role of anti-inflammatory drugs remains important but should be limited to the smallest dose for the shortest period of time, especially with the emerging concern about long-term toxicity.9 There appears to be no effective role for complementary medicine even though many patients will be keen to try alternative therapies.7
Additional to the management of the underlying inflammatory disease is the management of symptoms such as pain and poor sleep quality.7
Patient education is very important to help enhance their understanding of the disease, and the GP plays an important part in supporting the patients to learn about and manage this significant chronic disease.7 Patients will require an exercise programme, which should form an ongoing part of their treatment. Aerobic exercises are best, and for most patients exercise is beneficial. However, if the patients have severely active inflammatory disease, then rest is preferable until the disease is better controlled. Such patients can be offered steroid injections to get rapid disease control, so that they can then take part in aerobic exercise.
All patients should be encouraged to pace their activities and protect their joints against undue and inefficient movements, which might lead to damage in the future. Hand exercises are beneficial, but the use of splints should be confined to when the joints are actively swollen or painful. There is limited evidence that devices, such as a transcutaneous electrical nerve stimulation (TENS) machine, are effective; and the role of hot and cold applications is primarily for short-term relief and not for long-term improvement as there is no evidence of a long-lasting benefit.7 Foot care is important, and attention to good foot hygiene remains imperative.7
Complications in pregnancy
A discussion of sexual health and pregnancy should form part of the management of patients in the appropriate age group who have early RA. The use of medication during pregnancy and breastfeeding needs to be discussed with patients prior to conception, if possible. For example, some drugs such as methotrexate would be contraindicated during pregnancy. It is important to ensure that the drug therapy is stopped early enough to avoid causing toxicity to the foetus. Most drugs are excreted in breast milk and, therefore, if patients have a flare-up of disease after giving birth, it may not always be possible to breastfeed since they will need to start medication to control the RA.
This guideline should provide clear information to primary care practitioners, and improve the communication between primary and secondary care by establishing the optimal requirements for RA patients. This will ultimately lead to better management, and a reduction in morbidity and long-term mortality from this disease.
- Wiles N, Symmons D, Harrison B et al. Estimating the incidence of rheumatoid arthritis: trying to hit a moving target? Arthritis Rheum 1999; 42 (7): 1339–1346.
- Young A, Dixey J, Kulinskaya E et al. Which patients stop working because of rheumatoid arthritis? Results of five years' follow up in 732 patients from the Early RA Study (ERAS). Ann Rheum Dis 2002; 61 (4): 335–340.
- Solomon D, Karlson E, Rimm E et al. Cardiovascular morbidity and mortality in women diagnosed with rheumatoid arthritis. Circulation 2003; 107 (9): 1303–1307.
- Smolen J, Steiner G. Therapeutic strategies for rheumatoid arthritis. Nat Rev Drug Discov 2003; 2 (6): 473–488.
- Scott D, Kingsley G. Tumor necrosis factor inhibitors for rheumatoid arthritis. N Engl J Med 2006; 355 (7): 704–712.
- Roberts L, Cleland L, Thomas R et al. Early combination disease modifying antirheumatic drug treatment for rheumatoid arthritis. Med J Aust 2006; 184 (3): 122–125.
- 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 treatment but a shortage of rheumatologists. Arthritis Rheum 2002; 46 (4): 851–854.
- Graham D, Campen D, Hui R et al. Risk of acute myocardial infarction and sudden cardiac death in patients treated with cyclo-oxygenase 2 selective and non-selective non-steroidal antiinflammatory drugs: nested case-control study. Lancet 2005; 365 (9458): 475–481.