rheumatoid arthritis

234 Pages·2009·1.58 MB·English

by  Dan Thorneycroft

The National Collaborating Centre
for Chronic Conditions
Funded to produce guidelines for the NHS by NICE
RHEUMATOID ARTHRITIS
National clinical guideline for management
and treatment in adults
Published by
Royal College of Physicians
The Royal College of Physicians plays a leading role in the delivery of high-quality patient care
by setting standards of medical practice and promoting clinical excellence. We provide physicians
in the United Kingdom and overseas with education, training and support throughout their
careers. As an independent body representing over 20,000 Fellows and Members worldwide, we
advise and work with government, the public, patients and other professions to improve health
and healthcare.
National Collaborating Centre for Chronic Conditions
The National Collaborating Centre for Chronic Conditions (NCC-CC) is a collaborative,
multiprofessional centre undertaking commissions to develop clinical guidance for the
National Health Service (NHS) in England and Wales. The NCC-CC was established in 2001.
It is an independent body, housed within the Clinical Standards Department at the Royal
College of Physicians of London. The NCC-CC is funded by the National Institute for Health
and Clinical Excellence (NICE) to undertake commissions for national clinical guidelines on
an annual rolling programme.
Citation for this document
National Collaborating Centre for Chronic Conditions. Rheumatoid arthritis: national clinical
guideline for management and treatment in adults. London: Royal College of Physicians,
February 2009.
ISBN 978-1-86016-359-3
ROYAL COLLEGE OF PHYSICIANS
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Copyright © 2009 Royal College of Physicians of London
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Printed in Great Britain by The Lavenham Press Ltd, Sudbury, Suffolk
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 incidence 5
1.4 Management principles 6
1.5 Health and resource burden 7
1.6 Living with RA 7
2 Methodology
2.1 Aim 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
2.8 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 investigations
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 multidisciplinary team 71
6.2 Physiotherapy 76
6.3 Occupational therapy 87
6.4 Podiatry 95
© Royal College of Physicians, 2009. All rights reserved. iii
Rheumatoid arthritis
7 Pharmacological management
7.1 Disease modifying antirheumatic drugs (DMARDs) 101
7.1 A Introducing disease-modifying drugs (DMARDs) 101
7.1 B Optimal sequencing of disease-modifying drugs (DMARDs) 108
7.1 C Disease-modifying and biological drugs: when to withdraw them 128
7.2 Glucocorticoids 135
7.3 Biologics 141
7.3 A Biological drugs and conventional DMARDs in patients with 141
established RA where there is ongoing disease activity
7.3 B Anakinra 157
7.4 Symptom control 162
7.4 A Analgesics 162
7.4 B NSAIDs 166
8 Monitoring rheumatoid arthritis
8.1 Monitoring disease 181
8.2 Content and frequency of review 186
8.3 Timing and referral for surgery 189
9 Other aspects 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/pubs/brochure.aspx?e=271
A Clinical questions and literature search
B Scope of the guideline
C Disease modifying antirheumatic drug combinations in early rheumatoid
arthritis: a cost-effective analysis
D Declaration of interests (GDG members)
iv © Royal College of Physicians, 2009. All rights reserved.
Guideline Development Group members
Dr Michael Rudolf (Chair)
Chair, NCC-CC; Respiratory Physician, Ealing Hospital NHS Trust
Dr Chris Deighton
Clinical Advisor, NCC-CC; Consultant Rheumatologist, Derby Hospitals
NHS Foundation Trust
Mrs Ailsa Bosworth
Patient and Carer Representative, Maidenhead
Dr Jane Hall
Senior Clinical Research Physiotherapist and Honorary Senior Lecturer RACE/Physiotherapy
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 Teaching Hospital
Dr Patrick Kiely
Consultant Rheumatologist, St George’s NHS Healthcare Trust, London
Dr Raashid Luqmani
Consultant Rheumatologist, Nuffield Orthopaedic Centre and University of Oxford
Dr David Morgan
General Practitioner (non RA specialist), Birmingham
Dr Rachel O’Mahony
Senior Research Fellow, NCC-CC
Mrs Enid Quest
Patient and Carer Representative, Bristol
Mrs Isabel Raiman
Community based nurse, Brighton and Hove City Teaching PCT
Mrs Alison Richards
Information Scientist, NCC-CC
Professor David L Scott
Consultant Rheumatologist, Kings College Hospital
Ms Jaim Sutton
Project Manager, NCC-CC – until March 2008
Mr Jonathan Tosh
Health Economist, ScHARR, University of Sheffield
Ms Claire Turner
Senior Project Manager, NCC-CC – from April 2008
Dr Louise Warburton
General Practitioner (specialist in RA), Shrewsbury
© Royal College of Physicians, 2009. All rights reserved. v
Rheumatoid arthritis
The following individuals acted as either deputies for GDG members or were invited experts:
Ms Zara Bingham
Patient and carer representative (acted as a deputy for Alisa Bosworth at a GDG meeting),
Manchester
Dr Paul D’Orso
General Practitioner (non RA specialist), Birmingham
(acted as a deputy for Dr Morgan for one meeting)
Mr Colin Howie
Consultant Orthopaedic and Trauma Surgeon, Edinburgh New Royal Infirmary
(invited expert attended one GDG meeting)
Dr Anthony Redmond
Podiatrist & Senior Lecturer, University of Leeds (invited expert attended two GDG meetings)
Mr Andrew Robinson
Consultant Foot and Ankle Surgeon, Cambridge University Hospital NHS Trust
(invited expert attended one GDG meeting)
Dr Joanna Sheldon
Immunologist, St George’s Hospital, London (invited expert attended one GDG meeting)
vi © Royal College of Physicians, 2009. All rights reserved.
Acknowledgements
Acknowledgements
The Guideline Development Group is grateful to the following people for their valuable
contributions to the development of this guideline:
(cid:2) Dr Bernard Higgins, Director, NCC-CC
(cid:2) Ms Jane Ingham, Assistant Director Implementation, NCC-CC
(cid:2) Ms Jill Parnham, Assistant Director Operations, NCC-CC
(cid:2) Mr Rob Grant, Senior Technical Advisor
(cid:2) Dr Allan Wailoo, Senior Health Economist, ScHARR, University of Sheffield
(cid:2) Dr Alan Brennan, Director of Health Economics and Decision Science, ScHARR,
University of Sheffield
(cid:2) Ms Susan Tann, Coordinator, NCC-CC
© Royal College of Physicians, 2009. All rights reserved. vii
Preface
There are over 400,000 people with rheumatoid arthritis (RA) in the UK. Although this makes
it a common disorder, there are numerous other conditions ahead of it in terms of numbers,
and indeed as causes of excess mortality. What this does not capture however, is the dreadful
morbidity associated with the disease. The synovitis of RA affects multiple sites causing
widespread pain, and the subsequent destruction of the joints can lead to severe disability
affecting all aspects of motor function from walking to fine movements of the hand. Further-
more, RA is not simply a disease of the joints but can affect many other organs causing, for
example, widespread vasculitis or severe lung fibrosis. More recently it has become apparent
that RA is associated with an increased prevalence of coronary artery disease and significant
increased risk of premature mortality.
Fortunately there are a considerable number of disease-modifying and anti-inflammatory agents
which can significantly reduce the impact of RA. Some of these, for example corticosteroids,
sulphasalazine or methotrexate, have been available for many years, and rheumatologists are well
used to balancing the benefits and side-effects of these drugs. More recently, targeted disease-
modifying and anti-inflammatory therapies, particularly the anti-TNF agents, have emerged, and
have proved effective in many patients. While it is encouraging that there is such a wide range of
treatment available, the choice brings with it difficult questions concerning the best sequencing
of therapy. Moreover, the newer drugs are expensive. The high impact of the disease and the need
to make best use of the available treatment make RA a highly suitable subject for a NICE
guideline, which it is now my pleasure to introduce.
I have already touched on the exciting therapeutic options for RA, but this guideline addresses
many other aspects of management. Because established RA has so many classical features it is
easy to forget that at presentation the diagnosis may not be readily apparent, yet early
intervention may be important. The guideline offers advice on this problem, including a
consideration of the place of newer serological markers of the disease, particularly anti-CCP
antibodies. The role of objective measures in the monitoring of disease activity is also
considered, as an important component of achieving and maintaining control. The importance
of non-pharmacological management of RA is also emphasised, including the many therapeutic
interventions which are usually supervised by physiotherapists, occupational therapists and
podiatrists; as is the crucial role of the multidisciplinary team including these professionals as
well as specialist nurses and doctors.
As in all NICE guidelines, recommendations are based on best available evidence interpreted by
a Guideline Development Group (GDG) whose members have expertise and experience in all
aspects of managing RA. This GDG have been a huge pleasure to work with. They have shown
enormous enthusiasm for the task and for working with NICE to produce the best possible
guidance for those suffering from RA. They have done this with a tremendous group spirit and
constant good humour, and they fully deserve the thanks which I now offer to them on behalf
of all those working at the NCC-CC. I hope that their guidance is as influential as it deserves to
be; I believe it should help to improve the care of all people with RA.
Dr Bernard Higgins MD FRCP
Director, National Collaborating Centre for Chronic Conditions
© Royal College of Physicians, 2009. All rights reserved. ix
Acronyms, abbreviations and glossary
Acronyms and abbreviations
ABA Abatacept
ACR American College of Rheumatology (see ARA)
ACR20, 50, 70 ACR criteria 20, 50, 70
ADA Adalimumab
ADL Activities of daily living
AEs Adverse events
AIMS Arthritis Impact Measurement Scale
AL-TENS Acupuncture-like transcutaneous electrical nerve stimulation
Anti-CCP Anti-cyclic citrullinated peptide
Anti-TNF Anti-tumor necrosis factor
ARA American Rheumatism Association (now ACR)
ARMA Arthritis and Musculoskeletal Alliance
AUC Area under the curve
ARC Arthritis Research Campaign
BMI Body mass index
BSR British Society of Rheumatology
CBT Cognitive behavioral therapy
CI Confidence interval (95% unless stated otherwise)
COX-2 Cyclooxegenase-2
CRP C-reactive protein
CS Corticosteroid
CsA Cyclosporin A
CTX Cyclophosphamide
CV Cardio-vascular
DAS (DAS28, Disease Activity Score
DAS32)
DMARD Disease modifying antirheumatic drug
EA Electroacupuncture
EQ-5D EuroQol 5-dimensional outcomes questionnaire
EOW, eow Every other week
ESR Erythrocyte sedimentation rate
ETN Etanercept
EULAR The European League against Rheumatism
EW, ew Every week
GDG Guideline development group
GI Gastrointestinal
x © Royal College of Physicians, 2009. All rights reserved.
Acronyms, abbreviations and glossary
HAQ Stanford health assessment questionnaire score
HCQ Hydroxychloroquine
IA Inflammatory arthritis, or Intra-articular
ICER Incremental cost-effectiveness ratio
IFX Infliximab
IM Intramuscular
IRGL Impact of Rheumatic Diseases on General Health and Lifestyle Questionnaire
ITT Intention to treat analysis
IV/iv Intravenous
JSN Joint space narrowing
LASER Light amplification by stimulated emission of radiation
MA Meta-analysis
MACTAR McMaster Toronto Arthritis Patient Preference Disability Questionnaire
MCP Metacarpophalangeal joint
MD Mean difference
MDT Multidisciplinary team
MTP Metatarsophalangeal joint
MTX Methotrexate
MHRA Medicines and Healthcare products Regulatory Agency
MI Myocardial infarction
NCC-CC National Collaborating Centre for Chronic Conditions
NHS National Health Service; this guideline is intended for use in the NHS in
England and Wales
NICE National Institute for Health and Clinical Excellence
NS Not significant (at the 5% level unless stated otherwise)
NSAID Non-steroidal anti-inflammatory drugs
NRAS National Rheumatoid Arthritis Society
OMERACT Outcome Measures in Rheumatoid Arthritis Clinical Trials
OR Odds ratio
OT Occupational therapy or therapist
PIP Proximal interphalangeal joint
PPI Proton pump inhibitor
PPV Positive predictive value
PUFA Polyunsaturated fatty acid
QALY Quality-adjusted life-year
QoL Quality of Life
RAI Ritchie Articular Index
RCT Randomised controlled trial
RF Rheumatoid factor
ROM Range of motion
© Royal College of Physicians, 2009. All rights reserved. xi