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Rheumatoid arthritis

About

What is covered

This interactive flowchart covers the management of rheumatoid arthritis in adults.
Rheumatoid arthritis is a painful, progressive disease that largely affects synovial joints. It typically affects the small joints of the hands and the feet, and usually both sides equally and symmetrically, although any synovial joint can be affected. It is a systemic disease and so can affect the whole body, including the heart, lungs and eyes.
The overall occurrence of rheumatoid arthritis is 2 to 4 times greater in women than men. The peak age of incidence in the UK for both genders is the 70s, but people of all ages can develop the disease.
Drug treatment aims to relieve symptoms, as pain relief is the priority for people with rheumatoid arthritis, and to modify the disease process. Disease modification slows or stops radiological progression. Radiological progression is closely correlated with progressive functional impairment.
The Guideline Development Group for rheumatoid arthritis (NICE guideline CG79) considered a clinical diagnosis of rheumatoid arthritis more useful than the 1987 American Rheumatism Association classification criteria. This is because early persistent synovitis in which other pathologies have been ruled out needs to be treated as if it is rheumatoid arthritis to minimise damage to joints.

Updates

Updates to this interactive flowchart

10 October 2017 Tofacitinib for moderate to severe rheumatoid arthritis (NICE technology appraisal guidance 480) added to drug treatment for rheumatoid arthritis.
8 August 2017 Baricitinib for moderate to severe rheumatoid arthritis (NICE technology appraisal guidance 466) added.
25 October 2016 Structure revised and summarised recommendations replaced with full recommendations. Certolizumab pegol for treating rheumatoid arthritis after inadequate response to a TNF-alpha inhibitor (NICE technology appraisal guidance 415) added.
25 January 2016 Adalimumab, etanercept, infliximab, certolizumab pegol, golimumab, tocilizumab and abatacept for rheumatoid arthritis not previously treated with DMARDs or after conventional DMARDs only have failed (NICE technology appraisal guidance 375) added to second-line treatment.
8 December 2015 Recommendations in management by the multidisciplinary team amended in line with the update of NICE guideline CG79 on rheumatoid arthritis in adults.
26 August 2014 Total prosthetic replacement of the temporomandibular joint (NICE interventional procedures guidance 500) added to surgical treatment.
25 February 2014 Total hip replacement and resurfacing arthroplasty for end-stage arthritis of the hip (NICE technology appraisal 304) added to surgical treatment.
28 June 2013 Rheumatoid arthritis in over 16s (NICE quality standard 33) added.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Short Text

Everything NICE has said on managing rheumatoid arthritis in adults in an interactive flowchart

What is covered

This interactive flowchart covers the management of rheumatoid arthritis in adults.
Rheumatoid arthritis is a painful, progressive disease that largely affects synovial joints. It typically affects the small joints of the hands and the feet, and usually both sides equally and symmetrically, although any synovial joint can be affected. It is a systemic disease and so can affect the whole body, including the heart, lungs and eyes.
The overall occurrence of rheumatoid arthritis is 2 to 4 times greater in women than men. The peak age of incidence in the UK for both genders is the 70s, but people of all ages can develop the disease.
Drug treatment aims to relieve symptoms, as pain relief is the priority for people with rheumatoid arthritis, and to modify the disease process. Disease modification slows or stops radiological progression. Radiological progression is closely correlated with progressive functional impairment.
The Guideline Development Group for rheumatoid arthritis (NICE guideline CG79) considered a clinical diagnosis of rheumatoid arthritis more useful than the 1987 American Rheumatism Association classification criteria. This is because early persistent synovitis in which other pathologies have been ruled out needs to be treated as if it is rheumatoid arthritis to minimise damage to joints.

Updates

Updates to this interactive flowchart

10 October 2017 Tofacitinib for moderate to severe rheumatoid arthritis (NICE technology appraisal guidance 480) added to drug treatment for rheumatoid arthritis.
8 August 2017 Baricitinib for moderate to severe rheumatoid arthritis (NICE technology appraisal guidance 466) added.
25 October 2016 Structure revised and summarised recommendations replaced with full recommendations. Certolizumab pegol for treating rheumatoid arthritis after inadequate response to a TNF-alpha inhibitor (NICE technology appraisal guidance 415) added.
25 January 2016 Adalimumab, etanercept, infliximab, certolizumab pegol, golimumab, tocilizumab and abatacept for rheumatoid arthritis not previously treated with DMARDs or after conventional DMARDs only have failed (NICE technology appraisal guidance 375) added to second-line treatment.
8 December 2015 Recommendations in management by the multidisciplinary team amended in line with the update of NICE guideline CG79 on rheumatoid arthritis in adults.
26 August 2014 Total prosthetic replacement of the temporomandibular joint (NICE interventional procedures guidance 500) added to surgical treatment.
25 February 2014 Total hip replacement and resurfacing arthroplasty for end-stage arthritis of the hip (NICE technology appraisal 304) added to surgical treatment.
28 June 2013 Rheumatoid arthritis in over 16s (NICE quality standard 33) added.

Sources

NICE guidance and other sources used to create this interactive flowchart.
Rheumatoid arthritis in adults: management (2009 updated 2015) NICE guideline CG79
Tofacitinib for moderate to severe rheumatoid arthritis (2017) NICE technology appraisal guidance 480
Baricitinib for moderate to severe rheumatoid arthritis (2017) NICE technology appraisal guidance 466
Tocilizumab for the treatment of rheumatoid arthritis (2012) NICE technology appraisal guidance 247
Total prosthetic replacement of the temporomandibular joint (2014) NICE interventional procedures guidance 500
Minimally invasive total hip replacement (2010) NICE interventional procedures guidance 363
Shoulder resurfacing arthroplasty (2010) NICE interventional procedures guidance 354
Total wrist replacement (2008) NICE interventional procedures guidance 271
Metatarsophalangeal joint replacement of the hallux (2005) NICE interventional procedures guidance 140
Rheumatoid arthritis in over 16s (2013) NICE quality standard 33

Quality standards

Rheumatoid arthritis in over 16s

These quality statements are taken from the rheumatoid arthritis in over 16s quality standard. The quality standard defines clinical best practice for rheumatoid arthritis and should be read in full.

Quality statements

Referral

This quality statement is taken from the rheumatoid arthritis in over 16s quality standard. The quality standard defines clinical best practice for rheumatoid arthritis in over 16s and should be read in full.

Quality statement

People with suspected persistent synovitis affecting the small joints of the hands or feet, or more than 1 joint, are referred to a rheumatology service within 3 working days of presentation.

Rationale

Rapid referral of people with suspected persistent synovitis is important to avoid delay in diagnosis and increase the likelihood of early treatment initiation. Given the potentially devastating effects of delayed diagnosis in terms of joint damage and quality of life, people with these symptoms and signs should be considered to need urgent action.

Quality measure

Structure
Evidence of local arrangements for people with suspected persistent synovitis affecting the small joints of the hands or feet, or more than 1 joint, to be referred to a rheumatology service within 3 working days of presentation.
Process
Proportion of people with suspected persistent synovitis affecting the small joints of the hands or feet, or more than 1 joint, who are referred to a rheumatology service within 3 working days of presentation.
Numerator – the number of people in the denominator who are referred to a rheumatology service within 3 working days of presentation.
Denominator – the number of people with suspected persistent synovitis affecting the small joints of the hands or feet or more than 1 joint.

Description of what the quality statement means for each audience

Service providers ensure systems are in place for people with suspected persistent synovitis affecting the small joints of the hands or feet, or more than 1 joint, to be referred to a rheumatology service within 3 working days of presentation.
Primary care professionals ensure that people with suspected persistent synovitis affecting the small joints of the hands or feet, or more than 1 joint, are referred to a rheumatology service within 3 working days of presentation.
Commissioners ensure they commission services that enable people with suspected persistent synovitis affecting the small joints of the hands or feet, or more than 1 joint, to be referred to a rheumatology service within 3 working days of presentation.
People with suspected persistent synovitis (inflammation of the joints) affecting the small joints of the hands or feet, or more than 1 joint, are referred to a rheumatology service within 3 working days of first reporting the problem.

Source clinical guideline references

NICE clinical guideline 79 recommendation 1.1.1.1 (key priority for implementation).

Data source

Structure
Local data collection.
Process
Local data collection. Contained within the British Society for Rheumatology National clinical audit for rheumatoid and early inflammatory arthritis.

Definitions

Timeframe derived from expert consensus.
Symptoms and signs of persistent synovitis include persistent (not resolving within 3 or 4 weeks) pain, swelling, heat, early morning stiffness lasting more than 30 minutes and often recurring after longer periods of rest, and loss of function of the affected joint. Occasionally the joints may also be red, but this is unusual. The person may also have systemic symptoms of inflammation, which include malaise, fever, sweats, fatigue and weight loss.
Any person with suspected persistent synovitis of undetermined cause whose blood tests show a normal acute-phase response or negative rheumatoid factor should still be referred urgently as they may still have rheumatoid arthritis.
A rheumatology service comprises a specialist multidisciplinary team, all of whom have expertise in managing rheumatoid arthritis. The team is led by 1 or more consultant rheumatologists and includes nurse specialists, physiotherapists, occupational therapists, podiatrists and orthotists. It has access to supporting specialties including orthopaedic surgery, psychology, radiology with rheumatological ultrasound and MRI experience, and may also have rheumatology doctors in training.

Assessment

This quality statement is taken from the rheumatoid arthritis in over 16s quality standard. The quality standard defines clinical best practice for rheumatoid arthritis in over 16s and should be read in full.

Quality statement

People with suspected persistent synovitis are assessed in a rheumatology service within 3 weeks of referral.

Rationale

Rapid assessment in a rheumatology service is important to avoid delay in diagnosis and increase the likelihood of early treatment initiation. Given the potentially devastating effects of delayed diagnosis in terms of joint damage and quality of life, people with these symptoms and signs need to be assessed quickly.

Quality measure

Structure
Evidence of local arrangements for people with suspected persistent synovitis to be assessed in a rheumatology service within 3 weeks of referral.
Process
Proportion of people with suspected persistent synovitis who are assessed in a rheumatology service within 3 weeks of referral.
Numerator – the number of people in the denominator who are assessed in a rheumatology service within 3 weeks of referral.
Denominator – the number of people with suspected persistent synovitis referred to a rheumatology service.

Description of what the quality statement means for each audience

Service providers ensure systems are in place for people with suspected persistent synovitis to be assessed in a rheumatology service within 3 weeks of referral.
Healthcare professionals ensure that people with suspected persistent synovitis are assessed in a rheumatology service within 3 weeks of referral.
Commissioners ensure they commission services that enable people with suspected persistent synovitis to be assessed in a rheumatology service within 3 weeks of referral.
People with suspected persistent synovitis (inflammation of the joints) are assessed in a rheumatology service within 3 weeks of referral.

Source clinical guideline references

NICE clinical guideline 79 recommendation 1.1.1.1 (key priority for implementation).

Data source

Structure
Local data collection.
Process
Local data collection. Contained within the British Society for Rheumatology National clinical audit for rheumatoid and early inflammatory arthritis and within the Commissioning for Quality in Rheumatoid Arthritis (CQRA) Patient metric data collection form for recent onset rheumatoid arthritis.

Definitions

Timeframe derived from expert consensus and is consistent with best practice (as defined in the (2013–14 best practice tariff for early inflammatory arthritis).
Symptoms and signs of persistent synovitis include persistent (not resolving within 3 or 4 weeks) pain, swelling, heat, early morning stiffness lasting more than 30 minutes and often recurring after longer periods of rest, and loss of function of the affected joint. Occasionally the joints may also be red, but this is unusual. The person may also have systemic symptoms of inflammation, which include malaise, fever, sweats, fatigue and weight loss.
A rheumatology service comprises a specialist multidisciplinary team, all of whom have expertise in managing rheumatoid arthritis. The team is led by 1 or more consultant rheumatologists and includes nurse specialists, physiotherapists, occupational therapists, podiatrists and orthotists. It has access to supporting specialties including orthopaedic surgery, psychology, radiology with rheumatological ultrasound and MRI experience, and may also have rheumatology doctors in training.

Starting treatment

This quality statement is taken from the rheumatoid arthritis in over 16s quality standard. The quality standard defines clinical best practice for rheumatoid arthritis in over 16s and should be read in full.

Quality statement

People with newly diagnosed rheumatoid arthritis are offered short-term glucocorticoids and a combination of disease-modifying anti-rheumatic drugs by a rheumatology service within 6 weeks of referral.

Rationale

Rapid initiation of treatment optimises the 'window of opportunity' within which effective treatment can improve long-term outcomes such as joint damage, joint function and quality of life.

Quality measure

Structure
Evidence of local arrangements for people with newly diagnosed rheumatoid arthritis to receive short-term glucocorticoids and a combination of disease-modifying anti-rheumatic drugs from a rheumatology service within 6 weeks of referral.
Process
Proportion of people with newly diagnosed rheumatoid arthritis who receive short-term glucocorticoids and a combination of disease-modifying anti-rheumatic drugs from a rheumatology service within 6 weeks of referral.
Numerator – the number of people in the denominator who receive short-term glucocorticoids and a combination of disease-modifying anti-rheumatic drugs from a rheumatology service within 6 weeks of referral.
Denominator – the number of people with newly diagnosed rheumatoid arthritis.

Description of what the quality statement means for each audience

Service providers ensure systems are in place for people with newly diagnosed rheumatoid arthritis to be offered short-term glucocorticoids and a combination of disease-modifying anti-rheumatic drugs by a rheumatology service within 6 weeks of referral.
Healthcare professionals ensure that people with newly diagnosed rheumatoid arthritis are offered short-term glucocorticoids and a combination of disease-modifying anti-rheumatic drugs by a rheumatology service within 6 weeks of referral.
Commissioners ensure they commission services that enable people with newly diagnosed rheumatoid arthritis to be offered short-term glucocorticoids and a combination of disease-modifying anti-rheumatic drugs by a rheumatology service within 6 weeks of referral.
People with newly diagnosed rheumatoid arthritis are offered a short course of glucocorticoids (steroids) and a combination of drugs called DMARDs (disease-modifying anti-rheumatic drugs) by a rheumatology service within 6 weeks of referral.

Source clinical guideline references

NICE clinical guideline 79 recommendation 1.4.1.1 (key priority for implementation).

Data source

Structure
Local data collection.
Process
Local data collection. Contained within the British Society for Rheumatology National clinical audit for rheumatoid and early inflammatory arthritis and within the Commissioning for Quality in Rheumatoid Arthritis (CQRA) Patient metric data collection form for recent onset rheumatoid arthritis.

Definitions

Timeframe derived from expert consensus and is consistent with best practice (as defined in the (2013–14 best practice tariff for early inflammatory arthritis).
People with newly diagnosed rheumatoid arthritis are those attending the rheumatology service without a previous diagnosis of rheumatoid arthritis, who have been diagnosed after assessment within the service.
A rheumatology service comprises a specialist multidisciplinary team, all of whom have expertise in managing rheumatoid arthritis. The team is led by 1 or more consultant rheumatologists and includes nurse consultants, nurse specialists, physiotherapists, occupational therapists, podiatrists and orthotists. It has access to supporting specialties including orthopaedic surgery, psychology, radiology with rheumatological ultrasound and MRI experience, and may also have rheumatology doctors in training.
Monotherapy should be started in people with newly diagnosed rheumatoid arthritis for whom combination disease-modifying anti-rheumatic drug therapy is not appropriate (for example, because of comorbidities or pregnancy), and greater emphasis placed on fast escalation to a clinically effective dose rather than on the choice of disease-modifying anti-rheumatic drug.
People receiving treatment with disease-modifying anti-rheumatic drug therapy need frequent monitoring to check for any adverse events and assess response to treatment. Certain aspects of this monitoring may be delegated to other healthcare professionals and completed in non-specialist settings under formalised shared care arrangements.

Education and self-management

This quality statement is taken from the rheumatoid arthritis in over 16s quality standard. The quality standard defines clinical best practice for rheumatoid arthritis in over 16s and should be read in full.

Quality statement

People with rheumatoid arthritis are offered educational and self-management activities within 1 month of diagnosis.

Rationale

It is important to improve patients' understanding of rheumatoid arthritis and its management through educational activities and self-management programmes to enable them to get the best from their medication, learn how to better manage disease flares, pain and fatigue, and improve their overall quality of life. It is essential that the offer of educational and self-management activities is not a 'one-off', but is repeated throughout the course of the disease to ensure that people with rheumatoid arthritis have the opportunity to participate at a time, individual to them, that will support them to derive the greatest benefit.

Quality measure

Structure
Evidence of local arrangements for people with rheumatoid arthritis to be offered educational and self-management activities within 1 month of diagnosis.
Process
Proportion of people with rheumatoid arthritis who are offered educational and self-management activities within 1 month of diagnosis.
Numerator – the number of people in the denominator who are offered educational and self-management activities within 1 month of diagnosis.
Denominator – the number of people with rheumatoid arthritis.
Outcome
Patient experience.

Description of what the quality statement means for each audience

Service providers ensure systems are in place for people with rheumatoid arthritis to be offered educational and self-management activities within 1 month of diagnosis.
Healthcare professionals ensure that people with rheumatoid arthritis are offered educational and self-management activities within 1 month of diagnosis.
Commissioners ensure they commission services that enable people with rheumatoid arthritis to be offered educational and self-management activities within 1 month of diagnosis.
People with rheumatoid arthritis are offered educational activities and self-management programmes within 1 month of diagnosis.

Source clinical guideline references

NICE clinical guideline 79 recommendation 1.2.1.3.

Data source

Structure
Local data collection.
Process
Local data collection. Contained within the British Society for Rheumatology National clinical audit for rheumatoid and early inflammatory arthritis.
Outcome
Local data collection.

Definitions

Timeframe derived from expert consensus.
Educational activities and self-management programmes can be provided 1-to-1, through self-study or computer-based interventions or in formal organised group sessions led by rheumatology healthcare professionals or trained lay leaders with arthritis or other chronic conditions. Different formats may be used, and should include patient information supported by written resources, to improve understanding of the condition and its management, and counter any misconceptions people with rheumatoid arthritis may have. They may take an educational approach such as lecture or facilitated interactive group discussion sessions to increase knowledge and reduce concerns; or a behavioural approach, including regular skills practice, goal setting and use of home programmes to facilitate behavioural change.
Further support can be provided for people with rheumatoid arthritis by voluntary organisations such as support groups and charitable organisations, and it may be useful to provide sign-posting information at this point to ensure people know how to access further support once they have been diagnosed.
The opportunity to take part in existing educational activities and self-management programmes should be offered to people with rheumatoid arthritis throughout the course of their disease on an ongoing basis.

Disease control

This quality statement is taken from the rheumatoid arthritis in over 16s quality standard. The quality standard defines clinical best practice for rheumatoid arthritis in over 16s and should be read in full.

Quality statement

People who have active rheumatoid arthritis are offered monthly treatment escalation until the disease is controlled to an agreed low disease activity target.

Rationale

Monthly treatment escalation is important to achieving disease control rapidly, which results in a lower disease activity, and therefore reduced impact of the disease in terms of joint function and everyday living. The low disease activity target is agreed with the patient to maximise shared decision-making and patient satisfaction with their functional ability and suppression of symptoms.

Quality measure

Structure
Evidence of local arrangements to ensure that people with active rheumatoid arthritis receive monthly treatment escalation until the disease is controlled to an agreed low disease activity target.
Process
a) Proportion of people with active rheumatoid arthritis who receive monthly treatment escalation.
Numerator – the number of people in the denominator who receive monthly treatment escalation.
Denominator – the number of people with active rheumatoid arthritis.
b) Proportion of people with previously active rheumatoid arthritis whose disease is currently controlled, who received monthly treatment escalation until the disease was controlled to an agreed low disease activity target.
Numerator – the number of people in the denominator who received monthly treatment escalation until the disease was controlled to an agreed low disease activity target.
Denominator – the number of people with previously active rheumatoid arthritis whose disease is currently controlled.
Outcome
a) Controlled rheumatoid arthritis.
b) Functional ability.

Description of what the quality statement means for each audience

Service providers ensure systems are in place for people with active rheumatoid arthritis to be offered monthly treatment escalation until the disease is controlled to an agreed low disease activity target.
Healthcare professionals ensure that people with active rheumatoid arthritis are offered monthly treatment escalation until the disease is controlled to an agreed low disease activity target.
Commissioners ensure they commission services that enable people with active rheumatoid arthritis to be offered monthly treatment escalation until the disease is controlled to an agreed low disease activity target.
People with active rheumatoid arthritis are offered monthly increases in treatment dose until the disease is controlled to an agreed level.

Source clinical guideline references

NICE clinical guideline 79 recommendations 1.5.1.1 and 1.5.1.2 (key priority for implementation).

Data source

Structure
Local data collection.
Process
a) and b) Local data collection. Contained within the Commissioning for Quality in Rheumatoid Arthritis (CQRA) Patient metric data collection form for recent onset rheumatoid arthritis.
Outcome
a) and b) Local data collection.

Definitions

Active rheumatoid arthritis constitutes disease that cannot be considered as being adequately controlled to a level agreed between patient and rheumatologist. A disease activity score (measured using DAS28 for example) can be used to provide an objective indication of the level of activity, but a specific score cannot be prescribed for all patients as this is a matter for clinical judgement.
Treatment escalation relates to the use of disease-modifying antirheumatic drugs, glucocorticoids or biological drugs to control the disease (in accordance with relevant NICE technology appraisals), and a review of the treatment in terms of disease response and patient safety.
Disease activity is measured using a composite score such as DAS28.
An agreed low disease activity target is a level of low disease activity, ideally remission, or functional ability that is agreed with each person as their goal for ongoing management of the disease.
Controlled disease represents the agreed target being achieved and the person being satisfied with their functional ability and suppression of symptoms. Uncontrolled disease is any level of disease that doesn't meet the agreed target.
Functional ability can be measured using the Health Assessment Questionnaire.

Rapid access

This quality statement is taken from the rheumatoid arthritis in over 16s quality standard. The quality standard defines clinical best practice for rheumatoid arthritis in over 16s and should be read in full.

Quality statement

People with rheumatoid arthritis and disease flares or possible drug-related side effects receive advice within 1 working day of contacting the rheumatology service.

Rationale

It is important that people with rheumatoid arthritis experiencing disease flares or possible drug-related side effects are able to obtain advice from the rheumatology service rapidly, in order to prevent any further joint damage incurring. The sudden loss of function associated with a severe flare can be disabling and frustrating for people, and rapid involvement of a specialist in dealing with any possible drug-related side effects is essential from a patient safety perspective.

Quality measure

Structure
Evidence of local arrangements for people with rheumatoid arthritis and disease flares or possible drug-related side effects receive advice within 1 working day of contacting the rheumatology service.
Process
Proportion of people with rheumatoid arthritis and disease flares or possible drug-related side effects who receive advice within 1 working day of contacting the rheumatology service.
Numerator – the number of people in the denominator who receive advice within 1 working day of contacting the rheumatology service.
Denominator – the number of people with rheumatoid arthritis and disease flares or possible drug-related side effects who contact the rheumatology service.
Outcome
Patient experience.

Description of what the quality statement means for each audience

Service providers ensure systems are in place for people with rheumatoid arthritis and disease flares or possible drug-related side effects to receive advice within 1 working day of contacting the rheumatology service.
Healthcare professionals ensure that people with rheumatoid arthritis and disease flares or possible drug-related side effects receive advice within 1 working day of contacting the rheumatology service.
Commissioners ensure they commission services that enable people with rheumatoid arthritis and disease flares or possible drug-related side effects to receive advice within 1 working day of contacting the rheumatology service.
People with rheumatoid arthritis and disease flares or possible drug-related side effects receive advice within 1 working day of contacting the rheumatology service.

Source clinical guideline references

NICE clinical guideline 79 recommendation 1.5.1.3.

Data source

Structure
Local data collection.
Process
Local data collection. Contained within the British Society for Rheumatology National clinical audit for rheumatoid and early inflammatory arthritis.
Outcome
Local data collection.

Definitions

Timeframe derived from expert consensus.
A rheumatology service comprises a specialist multidisciplinary team, all of whom have expertise in managing rheumatoid arthritis. The team is led by 1 or more consultant rheumatologists and includes nurse specialists, physiotherapists, occupational therapists, podiatrists and orthotists. It has access to supporting specialties including orthopaedic surgery, psychology, radiology with rheumatological ultrasound and MRI experience, and may also have rheumatology doctors in training.

Annual review

This quality statement is taken from the rheumatoid arthritis in over 16s quality standard. The quality standard defines clinical best practice for rheumatoid arthritis in over 16s and should be read in full.

Quality statement

People with rheumatoid arthritis have a comprehensive annual review that is coordinated by the rheumatology service.

Rationale

Annual review is important to ensure that all aspects of the disease are under control. It provides a regular opportunity to holistically assess the patient in terms of the current management of the disease, and any further support they may need in the future, in order to enable them to maximise their quality of life.

Quality measure

Structure
Evidence of local arrangements for people with rheumatoid arthritis to have a comprehensive annual review that is coordinated by the rheumatology service.
Process
Proportion of people with rheumatoid arthritis diagnosed more than 1 year ago whose last comprehensive review was within 12 months of diagnosis or the previous review.
Numerator – the number of people in the denominator whose most recent comprehensive review was within 12 months of diagnosis or the previous review.
Denominator – the number of people with rheumatoid arthritis diagnosed more than 1 year ago.

Description of what the quality statement means for each audience

Service providers ensure systems are in place for people with rheumatoid arthritis to have a comprehensive annual review that is coordinated by the rheumatology service.
Healthcare professionals ensure that people with rheumatoid arthritis have a comprehensive annual review that is coordinated by the rheumatology service.
Commissioners ensure they commission services that enable people with rheumatoid arthritis to have a comprehensive annual review that is coordinated by the rheumatology service.
People with rheumatoid arthritis have a comprehensive annual review that is coordinated by the rheumatology service.

Source clinical guideline references

NICE clinical guideline 79 recommendation 1.5.1.4.

Data source

Structure
Local data collection.
Process
Local data collection. Contained within the British Society for Rheumatology National clinical audit for rheumatoid and early inflammatory arthritis and within the Commissioning for Quality in Rheumatoid Arthritis (CQRA) Patient metric data collection form for recent onset rheumatoid arthritis. See also, Quality and Outcomes Framework (QOF) indicators RA002, RA003 and RA004.

Definitions

A comprehensive annual review includes:
  • assessing disease activity and damage, and measuring functional ability (using, for example, the Health Assessment Questionnaire)
  • checking for the development of comorbidities, such as hypertension, ischaemic heart disease, osteoporosis and depression
  • assessing symptoms that suggest complications, such as vasculitis and disease of the cervical spine, lung or eyes
  • organising cross referral within the multidisciplinary team
  • assessing the need for referral for surgery
  • assessing the effect the disease is having on a person's life, for example their employment status and prospects (validated questionnaires are available for assessing quality of life)
  • symptom control and pain management
  • care planning
  • offering educational activities and self-management programmes.
It is not expected that all elements of the annual review would occur at the same time. Some aspects may be undertaken in primary care, for example checking for comorbidities such as hypertension.
Elements of the review may need to occur more or less often than once a year. For example, it may be most appropriate to assess for fracture risk at 24-month intervals, whereas advice on self-management or treatment review may occur more regularly.
A rheumatology service comprises a specialist multidisciplinary team, all of whom have expertise in managing rheumatoid arthritis. The team is led by 1 or more consultant rheumatologists and includes nurse specialists, physiotherapists, occupational therapists, podiatrists and orthotists. It has access to supporting specialties including orthopaedic surgery, psychology, radiology with rheumatological ultrasound and MRI experience, and may also have rheumatology doctors in training.
The rheumatology service is responsible for coordinating the annual review and ensuring that all elements have been completed (as well as preventing any duplication). An outpatient appointment could be arranged with a member of the rheumatology team to coordinate the review, and activities relating to the review should be documented in notes.
Action should be taken as necessary following the annual review, for example referral to specialist services.

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Implementation

Information for the public

NICE has written information for the public on each of the following topics.

Pathway information

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Supporting information

Why we made the recommendations on baricitinib

Clinical trials showed baricitinib plus conventional DMARDs to be more effective than conventional DMARDs alone for treating severe active rheumatoid arthritis that has not responded adequately to conventional or biological DMARDs. Some trial evidence also suggests that in people who have not previously had DMARDs, baricitinib works as well when taken alone as it does when taken with conventional DMARDs.
Baricitinib plus conventional DMARDs was also shown to have similar effectiveness to the biological DMARD adalimumab in people whose disease has responded inadequately to conventional DMARDs. Because there are no trials which compare baricitinib with other biological DMARDs, the company did an indirect comparison. Baricitinib was shown to work as well as most of the biological DMARDs which NICE has already recommended in this indication.
Based on the health-related benefits and costs compared with conventional and biological DMARDs, baricitinib plus conventional DMARDs was recommended as a cost-effective treatment, in line with previous recommendations in NICE technology appraisal guidance on:
For more information see the committee discussion in the NICE technology appraisal on baricitinib for moderate to severe rheumatoid arthritis.

Why we made the recommendations on tofacitinib

Clinical trial evidence shows tofacitinib plus conventional DMARDs is more effective than conventional DMARDs alone for treating moderate and severe active rheumatoid arthritis that has not responded adequately to conventional or biological DMARDs.
Clinical trial evidence also shows that tofacitinib plus methotrexate is not worse in effectiveness than the biological DMARD adalimumab plus conventional DMARDs in people whose disease has responded inadequately to conventional DMARDs. Because there are no trials comparing tofacitinib with other biological DMARDs, the company did an indirect comparison. This shows that tofacitinib works as well as most of the biological DMARDs which NICE has already recommended in this indication.
Based on the health-related benefits and costs compared with conventional and biological DMARDs, tofacitinib plus conventional DMARDs is recommended as a cost-effective treatment for severe active rheumatoid arthritis, in line with previous recommendations in NICE technology appraisal guidance on:
Tofacitinib for moderate active rheumatoid arthritis that has responded inadequately to conventional DMARDs is not cost effective based on what NICE normally considers acceptable, that is, £30,000 per quality-adjusted life year gained.
For more information see the committee discussion in the NICE technology appraisal on tofacitinib for moderate to severe rheumatoid arthritis.

Glossary

rheumatoid arthritis with a duration of up to 2 years; within recent-onset rheumatoid arthritis, categories of suspected persistent synovitis or suspected rheumatoid arthritis refer to patients in whom a diagnosis is not yet clear, but in whom referral to specialist care or further investigation is required
rheumatoid arthritis with a duration of longer than 2 years
disease-modifying anti-rheumatic drugs
tumour necrosis factor
disease activity score
non-steroidal anti-inflammatory drugs
cyclo-oxygenase 2
transcutaneous electrical nerve stimulators
Health Assessment Questionnaire
proton pump inhibitor
cyclic citrullinated peptide

Paths in this pathway

Pathway created: April 2013 Last updated: October 2017

© NICE 2017. All rights reserved. Subject to Notice of rights.

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