rheumatoid arthritis

248 Pages·2012·24.75 MB·English

The National Collaborating Centre
for Chronic Conditions
Funded to produce guidelines for the NHS o/ NICE
RHEUMATOID
ARTHRITIS
National clinical guideline for
management and treatment in adults
Published by
f t
Royal College
..
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T~e National Co//aboraling Centre
for C~ronic Conditions
RHEUMATOID ARTHRITIS
National clinical guideline for management
and treatment in adults
Published by
Royal College
of Physicians
S.U"'t ~ .......... ...,..,.
·----------------~~--------~----
Royal College of Physicians
The Royal CoUrge of Pbysic~ns play. a leading role in the delivery of high-q.Wity pauent carr
by setllng standards of mtdical practice and promoting clinicale=Uence. We provide physicians
in the Uniwl Kingdom and ove~as with education, lnlining and support throughout their
carem. As an independent body repri!SC'nllng over 20,000 Fellows and Mmtbers woddwKie. we
advise and work wtth government; the public, patients and other professions to improve health
and heahhcare.
National Collaboraliog Centre for Chronic Conditions
The National Collaborating Centre for Chronic Conditions {NCC-CC) is a collaborative,
muluprofessional ct:nln undttttking commissions to devtlop chnical guidance for the
National Health Service {NHS) in England and Wales. The NCC-CC was established in 200L
It is an independent body, housed within the Clinkal Standards Department at 1M Royal
College of Physicians of London. The NCC-CC is fundro by the National Institute for Health
and Chnical Excellence (NICE) to undertake commissions for national clinical guidelines on
an annual roUing programme.
Citation for this document
National Collaborating Centre for Chronic Conditions. Rheumatoid arthritis: nati011Q/ ell meal
guUkhne for managtmelll and treatment in adults. London: Royal College of Physic.ans,
February 2009.
ROYAL <XlU.EGE OF PHYS1CW1S
St-..,
II "'-.l.ondon NW1 4l£
www ,rcplcxKtol' .ec.ul(
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Contents
Guideline Development Group members v
Preface ix
Acronyms, abbreviations and glossary X
DEVELOPMENT OF THE GUIDELINE
1 Introduction
1.1 Background 3
1.2 Definition 4
1.3 Prevalence and inoldence 5
1.4 6
Manag~ntprinciples
1.5 Health and resource burden 7
1.6 LMng with RA 7
2 Methodology
2.1 Alm 9
2.2 Scope 9
2.3 Audience 9
2.4 Involvement of people with RA 9
2.5 Guideline limitations 10
2.6 Other work relevant to the guideline 10
2.7 Background 11
2.6 The process of guideline development 11
2.9 Disclaimer 16
2.10 Funding 16
3 Key messages of the guideline
3.1 Key priorities for implementation 17
3.2 Algorithm 18
THE GUIDELINE
4 Referral, diagnosis and Investigation•
4.1 Referral for specialist services 23
4.2 Presenting symptoms and signs 31
4.3 Investigations 44
5 Communication and education
5.1 Patient perceptions and beliefs 53
5.2 Patient education 61
6 The multidisciplinary team
6.1 The multidisciptinaly team 71
6.2 Physiotherapy 76
6.3 Occupational therapy 87
6.4 Podiatry 95
II
-
Rheumatoid arthritis
7 Pharmacologlcall!llln8gement
7.1 Ol$ease modifying antirheumatic drugs (DMARDs) lOt
7.1 ... lrcroducing ~tying drugs (OMAROs) 101
718 0p1Jma1 sequencing ol cisease.modifyi drugs (DMARDs) 108
71C Oisease-moclofy and biological drugs: when to wllhdraw lhem 128
7.2 Glucocorticoids 135
7.3 BIOlogiCS 141
7.3A Bdogocel drugs and eonventional DMAROs in patients with 141
eSiabloshed RA w11ete there Is ongoog disease aciMiy
738 Anllannl 157
7.4 Symptom coniJOI 162
7.4A Anllgesoca 162
748 NSAIDs
166
8 Monitoring rlleullllltold arthrttls
8 1 Mondonng dtsease
181
8.2 Content and frequency of review
186
8_3 Timing and referral for surgery
189
9 Other aspect• and treatment
9.1 Diet
195
9.2 Complementary therapies
200
10
NICE technology appraisal related recommendations
203
11
Areas for future research
205
REFERENCES
207
APPENDICES- online only at:
www.rcplondon.ac.uk/pubSibrochure.aspx?e=271
A crtnlcal questions and literature searCh
B Scope of 1he guideline
c
Oise~ modlfymg antirheumatic drug combinations in early rheumatoid
arlhrili$ a COS111fectlve analysis
0
Declarallon of interests (GOG members)
Guideline Development Group members
Or Michael Rudolf (Ciulir)
Chair, NCC-CC; Respiratory Physician, Ealing Hospital NHS Tmst
Dr Chris Deighton
Clinical Advisor, NCC-CC; Consultant Rheumatologist, Derby Hospitals
NHS foundation Trust
Mrs Ailsa Bosworth
Patient and Carer Representative, Maidenhead
Dr Jane !-{all
Senior Clinical Research Physiotherapist and Honorary Senior Lecturer RAC£/Pbysiotherapy
Royal National Hospital for Rheumatic Diseases and University of Bath
Dr Alison Hammond
Reader in Rheumatology Rehabilitation, University of Salford
Ms Sheena Hennell
Consultant Nurse, Wirral University Thaching Hospital
Or Patrick Kiely
Consultant Rheumatologist, St George's NHS Healthcare Trust, London
Dr Raashid Luqmani
Consultant Rheumatologist, Nufficld Orthopaedic Centre and University of Oxford
Dr David Morgan
General Practitioner (non RA specialist), Birmingham
Dr Rachel O'Mabooy
Senior Researc.b Fe.llow, NCC-CC
Mrs .Enid Quest
Patient and Carer Representative, Bristol
Mrs Isabel Raiman
Community based nurse, Brighton and HO\'e City Teaching PCT
Mrs Alison Richards
to formation Scientist, NCC-CC
Professor David l Scott
Consultant Rheumatologist, Kings College Hospital
Ms }aim Sutton
Project Managor, NCC-CC - until March 2008
Mr Jonathan Tosh
Health Economist, ScHARR, Univorsity ofS heffitld
Ms ClaiR 1\Jrn.r
Senior Project Manager, NCC-CC- from April2008
Dr Louise Warburton
General Practitioner (specialist in RA), Shrewsbury
v
The following individuals acted as rithtr deputies for GOG members or w~ invittd experu:
MaZuallinpam
Patitn1 and com rep~utive (acted as a depu!y for Aliso Boswonh at a GOG meeling).
Mmchcmr
Dr Po. . D'Ono
Cmn.J Practttiolltr (non RA sp«ialisl), Birmingh;am
(Ktcd ll a deputy tOr Dr Mo. ..n for one meeting)
Mt Colia Howie
eo.....lwl1 Orthopaedic and Trauma Surgeon, Edinburgh New Royal Infirmary
h~ ap<r~anended OM GOG meeting)
Dr Aalhoay Rldmond
Podtatnsll!t Stnoor l«turer, Un~Vntity of Leeds (invited expt'rt attended lwo GOG meetmp)
Mt Aadnw llobinsoo
Co. .u lunc Foot and Ankle Surgeon, Cambridge Universily Hospital NHS Trust
{invited apm attended onr GDC meeting)
Dr Joanna Shddon
Immunologist, St George's Hospit•l, london (invited expert attended one G DG meeting)
Acknowledgements
The Guiddine 0..-.lopment Group is gnt<fulto the following pt.Opk for theU" valuabk
contributions to the development of thiS guideline:
o Dr Bernard Higgins, Director, NCC-CC
o Ms Jane Tngham, Assistant Director Implementation, NCC-CC
o Ms Jill Parnham, Assistant Director Operations, NCC-CC
• Mr Rob Grant, Senior Technical Advisor
o Dr Allan Wailoo, Senior Health &:onomiSt, ScHARR, Univ.:rsity ofS heffield
o Dr Alan Brennan, Dirwor of Health &:onomics and Decision Science, ScHARR,
University ofSh¢1lield
o Ms Susan Tann. Coordinator, NCC-CC