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Rheumatoid arthritis

About

What is covered

This NICE Pathway covers diagnosing and managing rheumatoid arthritis in adults.

Updates

Updates to this NICE Pathway

8 January 2020 Rheumatoid arthritis in over 16s (NICE quality standard 33) updated.
9 July 2019 Therapeutic monitoring of TNF-alpha inhibitors in rheumatoid arthritis (NICE diagnostics guidance 36) added to monitoring and review.
10 July 2018 Full update on publication of rheumatoid arthritis in adults: management (NICE guideline NG100).
31 October 2017 Sarilumab for moderate to severe rheumatoid arthritis (NICE technology appraisal guidance 485) added to drug treatment for rheumatoid arthritis.
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.
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.
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 NICE Pathway covers diagnosing and managing rheumatoid arthritis in adults.

Updates

Updates to this NICE Pathway

8 January 2020 Rheumatoid arthritis in over 16s (NICE quality standard 33) updated.
9 July 2019 Therapeutic monitoring of TNF-alpha inhibitors in rheumatoid arthritis (NICE diagnostics guidance 36) added to monitoring and review.
10 July 2018 Full update on publication of rheumatoid arthritis in adults: management (NICE guideline NG100).
31 October 2017 Sarilumab for moderate to severe rheumatoid arthritis (NICE technology appraisal guidance 485) added to drug treatment for rheumatoid arthritis.
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.
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.
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 (2018) NICE guideline NG100
Sarilumab for moderate to severe rheumatoid arthritis (2017) NICE technology appraisal guidance 485
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
Rheumatoid arthritis in over 16s (2013 updated 2020) NICE quality standard 33
HemaClear for bloodless surgical field during limb surgery (2019) NICE medtech innovation briefing 187

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

Adults with suspected persistent synovitis affecting more than 1 joint, or the small joints of the hands and feet, are referred to rheumatology services within 3 working days of presenting in primary care.

Rationale

Rapid referral of adults with suspected persistent synovitis is important to avoid delay in diagnosis and treatment. Rapid referral is particularly important for adults with inflammation of more than 1 joint, or the small joints of the hands and feet because they are likely to have a poor prognosis. Early diagnosis and treatment of rheumatoid arthritis improves long-term outcomes, physical function and quality of life.

Quality measures

Structure
a) Evidence that healthcare professionals in primary care can recognise persistent synovitis.
Data source: Local data collection, for example, training records and evidence of continuous professional development covering inflammatory arthritis.
b) Evidence that systems are in place for adults with suspected persistent synovitis to be referred to rheumatology services within 3 working days of presentation.
Data source: Local data collection, for example, agreed referral pathways.
Process
Proportion of adults presenting in primary care with suspected persistent synovitis affecting more than 1 joint, or the small joints of the hands and feet, who are referred to rheumatology services within 3 working days.
Numerator – the number in the denominator who are referred to rheumatology services within 3 working days of presenting in primary care.
Denominator – the number of adults presenting in primary care with suspected persistent synovitis affecting more than 1 joint, or the small joints of the hands and feet.
Data source: The National Early Inflammatory Arthritis Audit collects data on referral within 3 working days of presentation.
Outcome
Time from presentation in primary care to diagnosis for adults with rheumatoid arthritis.
Data source: Local data collection, for example, audit of patient records.

What the quality statement means for different audiences

Service providers (such as GP practices) ensure that healthcare professionals can recognise the signs and symptoms of inflammatory arthritis. They agree pathways for urgent referral to rheumatology services (within 3 working days of presentation in primary care) of adults with suspected persistent synovitis of more than 1 joint, or the small joints of the hands and feet.
Healthcare professionals (such as GPs, nurses or allied health professionals) recognise the signs and symptoms of inflammatory arthritis and are aware of local referral pathways. They refer adults with suspected persistent synovitis of more than 1 joint, or the small joints of the hands and feet, to rheumatology services within 3 working days of presentation in primary care.
Commissioners (such as clinical commissioning groups) ensure that service specifications include referral criteria and referral pathways for adults presenting with suspected persistent synovitis of more than 1 joint, or the small joints of the hands or feet, to be referred to rheumatology services within 3 working days of presentation in primary care.
Adults with pain, swelling and stiffness of more than 1 joint, or the small joints of the hands or feet, are referred within 3 working days of their GP appointment to a specialist in rheumatology. Early referral means that they can be diagnosed and start treatment sooner if they have rheumatoid arthritis.

Source guidance

Definition of terms used in this quality statement

Persistent synovitis
Signs and symptoms of persistent synovitis include persistent (not resolving within 3 to 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 may include malaise, fever, sweats, fatigue and weight loss.
[Adapted from NICE’s full guideline on rheumatoid arthritis in adults, section 4.1 and from expert opinion]

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

Adults with active rheumatoid arthritis start conventional disease-modifying anti-rheumatic drug (cDMARD) monotherapy within 6 weeks of referral, with monthly monitoring until their treatment target is met.

Rationale

Starting treatment quickly give the best chance of improving long-term outcomes such as joint damage, joint function and quality of life for adults with active rheumatoid arthritis. Regular monitoring of C-reactive protein (CRP) and disease activity allows for the dose of cDMARDs to be adjusted as needed. Intensive treatment monitoring and adjustment, with the aim of maintaining remission, or low disease activity if remission cannot be achieved, results in better long-term function and quality of life for adults with rheumatoid arthritis.

Quality measures

Structure
a) Evidence of local arrangements to start treatment with cDMARD monotherapy for adults with active rheumatoid arthritis within 6 weeks of referral from primary care.
Data source: Local data collection, for example, service protocols and treatment strategies.
b) Evidence of local arrangements to measure CRP and disease activity monthly in adults with active rheumatoid arthritis until they are in remission or have low disease activity if remission cannot be achieved.
Data source: Local data collection, for example, service protocols and treatment strategies.
Process
a) Proportion of adults with suspected persistent synovitis who have specialist assessment within 3 weeks of referral from primary care.
Numerator – the number in the denominator who have specialist assessment within 3 weeks of referral.
Denominator – the number of adults with suspected persistent synovitis referred to rheumatology services.
Data source: The National Early Inflammatory Arthritis Audit collects data on time from referral to specialist assessment.
b) Proportion of adults with active rheumatoid arthritis starting cDMARD monotherapy within 6 weeks of referral from primary care.
Numerator – the number in the denominator who start cDMARD monotherapy within 6 weeks of referral.
Denominator – the number of adults with active rheumatoid arthritis referred to rheumatology services.
Data source: Local data collection, for example, audit of electronic prescription records. The National Early Inflammatory Arthritis Audit collects data on time from referral to initiation of cDMARD therapy.
c) Proportion of adults with active rheumatoid arthritis who have their CRP and disease activity score measured monthly.
Numerator – the number in the denominator who had their CRP and disease activity score measured within the past month.
Denominator – the number of adults with active rheumatoid arthritis.
Data source: Local data collection, for example, audit of patient records.
Outcome
a) Disease activity for adults with rheumatoid arthritis.
Data source: The National Early Inflammatory Arthritis Audit collects data on mean disease activity score (DAS28) at baseline, 3-month and 12-month follow-up.
b) Health-related quality of life for adults with rheumatoid arthritis.
Data source: The National Early Inflammatory Arthritis Audit collects data on patient-reported quality of life, including symptoms, wellbeing, impact on daily life and work, in the patient questionnaire at baseline, 3-month and 12-month follow-up.

What the quality statement means for different audiences

Service providers (such as rheumatology services) ensure that systems are in place for adults with active rheumatoid arthritis to start cDMARD monotherapy within 6 weeks of referral from primary care. They also ensure that staff from the multidisciplinary team are trained to perform monthly monitoring of active rheumatoid arthritis.
Healthcare professionals (such as rheumatology consultants, rheumatology specialist registrars and specialist nurses) start cDMARD monotherapy for adults with active rheumatoid arthritis within 6 weeks of referral. They measure CRP and disease activity monthly until the target of remission, or low disease activity if remission cannot be achieved, is met.
Commissioners (such as clinical commissioning groups) commission rheumatology services that have capacity for adults with active rheumatoid arthritis to start treatment with cDMARD monotherapy within 6 weeks of referral. They check whether services undertake monthly monitoring for adults with active disease.
Adults with active rheumatoid arthritis start treatment within 6 weeks of seeing their GP. They also have monitoring each month until they have achieved their treatment target.

Source guidance

Definitions of terms used in this quality statement

Treatment target
A treat-to-target strategy should be used for adults with rheumatoid arthritis. This defines a treatment target (such as remission or low disease activity if remission cannot be achieved) based on a composite score such as DAS28 and applies tight control (such as monthly monitoring with treatment adjustment) to reach this target. The treatment strategy often follows a protocol for adapting treatment depending on the disease activity level and degree of response to treatment.
[Adapted from NICE’s guideline on rheumatoid arthritis in adults, recommendations 1.2.1, 1.2.3 and terms used in this guideline]

Equality and diversity considerations

Some medicines used in the treatment of rheumatoid arthritis should not be prescribed for adults who are planning a pregnancy, pregnant or breastfeeding. Treatment goals may also be different during pregnancy or when breastfeeding. See the British Society for Rheumatology and British Health Professionals in Rheumatology guideline on prescribing DMARDs in pregnancy and breastfeeding.

Patient education

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

Adults with rheumatoid arthritis are given opportunities throughout the course of their disease to take part in educational activities that support self-management.

Rationale

It is important that adults with rheumatoid arthritis are involved in making decisions about their care and have a good understanding of their condition and its management. This enables them to get the best from their medicines, to better manage flare-ups, pain and fatigue, as well as improving their overall quality of life. To ensure they get the greatest benefit, it is essential that adults with rheumatoid arthritis are offered educational and self-management activities and signposting to resources provided by patient organisations, throughout the disease course and at times to suit individual needs.

Quality measures

Structure
Evidence of availability of educational activities for people with rheumatoid arthritis throughout the course of their disease.
Data source: Local data collection, for example, service protocols and treatment plans, or evidence of signposting to patient organisations documented in patient record.
Process
a) Proportion of adults with rheumatoid arthritis who are offered educational activities within 1 month of diagnosis.
Numerator – the number in the denominator who are offered educational activities within 1 month of diagnosis.
Denominator – the number of adults with rheumatoid arthritis.
Data source: Local data collection, for example, documentation in patient records or survey of adults with rheumatoid arthritis. The 2019/20 National Tariff Payment System collects data on adults with rheumatoid arthritis and early inflammatory arthritis who are offered education within 1 month of diagnosis.
b) Proportion of adults with rheumatoid arthritis who report at annual review that they have been given as much information as they want about their condition and its management.
Numerator – the number in the denominator who report that they have been given as much information as they want about their condition and its management.
Denominator – the number of adults with rheumatoid arthritis having an annual review.
Data source: Local data collection, for example, survey of adults with rheumatoid arthritis using the Commissioning for Quality in Rheumatoid Arthritis PREMS for RA: patient questionnaire, sections 1 and 3.
Outcome
Proportion of adults with rheumatoid arthritis who are satisfied with their ability to self-manage their condition.
Numerator – the number in the denominator who are satisfied with their ability to self-manage their condition.
Denominator – the number of adults with rheumatoid arthritis.
Data source: Local data collection, for example, using patient surveys.

What the quality statement means for different audiences

Service providers (such as rheumatology services) ensure that adults with rheumatoid arthritis are offered educational and self-management activities throughout their disease course. They ensure that staff have access to and knowledge of educational materials, structured programmes, and patient organisations for rheumatoid arthritis, and know how to communicate effectively with adults with rheumatoid arthritis to allow for shared decision making.
Healthcare professionals (such as rheumatology consultants, specialist nurses, and allied health professionals) offer adults with rheumatoid arthritis structured educational and self-management activities throughout the course of the disease. They offer verbal and written information at each appointment to improve the person’s understanding of their condition and its management. They provide opportunities for adults with rheumatoid arthritis to be involved in decisions on management of their disease and they signpost to relevant patient organisations.
Commissioners (such as clinical commissioning groups) commission services that provide educational and self-management activities for adults with rheumatoid arthritis and engage with patient organisations to provide additional support and resources.
Adults with rheumatoid arthritis take part in activities that help them to learn about their condition and what they can do to help themselves (self-management). These activities and resources should be available throughout the course of their disease. They are offered information to help them make decisions on managing their condition.

Source guidance

Definitions of terms used in this quality statement

Educational activities
Educational activities and self-management programmes can be provided 1-to-1 in a clinic setting, through self-study or computer-based interventions. They can also be provided 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 adults with rheumatoid arthritis may have. Educational activities may include lectures or facilitated interactive group discussions to increase knowledge and reduce concerns. Alternatively, regular skills practice, goal setting and home programmes may be used to facilitate behavioural change. The opportunity to take part in existing educational activities and self-management programmes should be offered to adults with rheumatoid arthritis throughout the course of their disease.

Equality and diversity considerations

Adults with rheumatoid arthritis should be provided with education and self-management materials and resources that they can easily read and understand themselves, or with support. Information should be in a format that suits their needs and preferences. It should be accessible to people who do not speak or read English, and it should be culturally and age appropriate. Adults with rheumatoid arthritis should have access to an interpreter or advocate if needed.
For people with additional needs related to a disability, impairment or sensory loss, information should be provided as set out in NHS England's Accessible Information Standard.
Adults with rheumatoid arthritis should be offered information about planning a pregnancy, pregnancy and breastfeeding at the time of diagnosis and throughout the course of their disease. The information should be appropriate to their age and circumstances.

Rapid access to specialist care

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

Adults with rheumatoid arthritis and disease flares or possible treatment-related side effects receive advice within 1-working-day of contacting rheumatology services.

Rationale

It is important that adults with rheumatoid arthritis and disease flares or treatment-related side effects can access rheumatology services rapidly to prevent any further joint damage. Rapid involvement of a specialist is essential for patient safety when there are side effects related to treatment. People may also need advice from members of the multidisciplinary team such as physiotherapists or occupational therapists, when they are having difficulties with activities of daily living.

Quality measures

Structure
a) Evidence of local arrangements for adults with rheumatoid arthritis to contact rheumatology services.
Data source: Local data collection, for example, service protocols. The National Early Inflammatory Arthritis Audit collects data on rheumatology services that provide contact details for a specialist advice line.
b) Evidence of availability of staff to give advice to adults with rheumatoid arthritis when they contact rheumatology services.
Data source: Local data collection, for example, staffing rotas.
Process
Proportion of adults with rheumatoid arthritis who receive advice from rheumatology services within 1 working day when experiencing a disease flare or possible treatment-related side effects.
Numerator – the number in the denominator who receive advice from rheumatology services within 1 working day.
Denominator – the number of adults with rheumatoid arthritis and a disease flare or possible treatment-related side effects who contact rheumatology services.
Data source: The National Early Inflammatory Arthritis Audit collects data on rheumatology services offering access to urgent rheumatology advice within 1 working day.
Outcome
a) Disease activity for adults with rheumatoid arthritis.
Data source: The National Early Inflammatory Arthritis Audit collects data on mean disease activity score (DAS28) at baseline, 3-month and 12-month follow-up.
b) Functional ability of adults with rheumatoid arthritis.
Data source: The National Early Inflammatory Arthritis Audit collects data on functional ability in the patient questionnaire at baseline, 3-month and 12-month follow-up.

What the quality statement means for different audiences

Service providers (such as rheumatology services) ensure that staff are available to give advice to adults with rheumatoid arthritis within 1 working day when they are experiencing disease flares or possible treatment-related side effects.
Healthcare professionals (such as rheumatology consultants, specialist nurses and allied health professionals) give advice within 1 working day when contacted by people with rheumatoid arthritis who have a disease flare or possible treatment-related side effects.
Commissioners (such as clinical commissioning groups) commission rheumatology services that have capacity to give advice when people with rheumatoid arthritis contact the service.
Adults with rheumatoid arthritis know who to contact and how to get advice quickly when they have a flare up of their condition or they have possible side effects from treatment.

Source guidance

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

Adults with rheumatoid arthritis have a comprehensive annual review that is coordinated by rheumatology services.

Rationale

Annual review is important to ensure that all aspects of rheumatoid arthritis are under control and quality of life is maximised. It provides an opportunity to assess how the person is managing their condition and to identify any further support they may need. This includes support from individual members of the multidisciplinary team. It provides an opportunity to assess disease activity and measure functional ability, check for comorbidities, such as cardiovascular disease and osteoporosis, and complications of rheumatoid arthritis, including vasculitis and disease of the spine, lung or eyes. It also provides an opportunity to establish how the disease is affecting a person’s life, including any effect on work and on psychological wellbeing.

Quality measures

Structure
Evidence of arrangements to ensure that adults with rheumatoid arthritis have a comprehensive annual review coordinated by rheumatology services.
Data source: Local data collection, for example, service specifications.
Process
Proportion of adults with rheumatoid arthritis diagnosed more than 12 months ago who had a comprehensive review within the past 12 months.
Numerator – the number in the denominator who had a comprehensive review within the past 12 months.
Denominator – the number of adults with rheumatoid arthritis diagnosed more than 12 months ago.
Data source: Local data collection, for example, audit of patient records. The National Early Inflammatory Arthritis Audit collects data on provision of an annual review by rheumatology services. The Quality and Outcomes Framework (QOF) indicator RA002 collects data on the provision in primary care of a face-to-face review in the preceding 12 months.
Outcome
Health-related quality of life for adults with rheumatoid arthritis.
Data source: The National Early Inflammatory Arthritis Audit collects data for patient-reported quality of life, including symptoms, wellbeing, impact on daily life and work at baseline, 3-month and 12-month follow-up as part of the patient questionnaire.

What the quality statement means for different audiences

Service providers (rheumatology services) coordinate comprehensive annual review for adults with rheumatoid arthritis. They ensure that systems are in place to invite adults with rheumatoid arthritis to attend an annual review and ensure that all elements of the review have been completed. This includes the use of protocols to refer to members of the multidisciplinary or surgical team when necessary.
Healthcare professionals (such as rheumatology consultants, specialist registrars, specialist nurses and GPs) provide a comprehensive annual review for all adults with rheumatoid arthritis. The review includes assessment of disease activity, functional ability and development of comorbidities or disease complications. They also assess the need for referral to other members of the multidisciplinary or surgical team. They have the expertise to assess the effect the disease is having on a person’s life.
Commissioners (such as clinical commissioning groups) ensure that service specifications include the provision of a comprehensive annual review for adults with rheumatoid arthritis. They monitor services to check whether these annual reviews are being done.
Adults with rheumatoid arthritis have a check-up each year. The check-up includes an assessment of rheumatoid arthritis and complications, as well as a check for heart disease, bone disease and depression. They are asked about how the rheumatoid arthritis is affecting their day-to-day life and are referred to other services (such as physiotherapy and occupational therapy) if needed.

Source guidance

Rheumatoid arthritis in adults: management (2018) NICE guideline NG100, recommendation 1.9.3

Definitions of terms used in this quality statement

Comprehensive annual review
A comprehensive annual review includes:
  • assessing disease activity and damage, and measuring functional ability (using, for example, the HAQ)
  • 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, lungs or eyes
  • organising appropriate cross-referral within the multidisciplinary team
  • assessing the need for referral for surgery
  • assessing the effect the disease is having on the person’s life.
The multidisciplinary team
A multidisciplinary approach to managing rheumatoid arthritis incorporates various health professions such as specialist nurses, physiotherapists, occupational therapists and podiatrists. The composition of the team may vary in an individual centre, but emphasis should be placed on the tasks required to care for the individual’s needs. The adult with rheumatoid arthritis can often be an active member of the team.

Equality and diversity considerations

Adults with rheumatoid arthritis should be offered information about planning a pregnancy, pregnancy and breastfeeding at annual review. The information should be appropriate to their age and circumstances.

Effective interventions library

Effective interventions library

Successful effective interventions library details

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.

Why we made the recommendations on sarilumab

Clinical trials showed sarilumab plus methotrexate or conventional DMARDs to be more effective than methotrexate or conventional DMARDs for treating moderate to severe active rheumatoid arthritis that has not responded adequately to conventional DMARDs. The trials also showed that for treating severe active rheumatoid arthritis that has not responded adequately to conventional DMARDs, sarilumab alone is more effective than adalimumab alone.
Because there are no trials comparing sarilumab with other biological DMARDs, the company did an indirect comparison. This showed that sarilumab with conventional DMARDs (including methotrexate) or alone works as well as most of the biological DMARDs that NICE has already recommended.
Based on the health-related benefits and costs compared with conventional and biological DMARDs, sarilumab plus methotrexate or sarilumab alone is recommended as a cost-effective treatment for severe active rheumatoid arthritis, in line with previous recommendations in NICE technology appraisal guidance on:

Rationale and impact: investigations following diagnosis

Rationale

Evidence showed that anti-CCP antibodies and radiographic damage at baseline were both important prognostic factors for subsequent radiographic progression. Anti-CCP antibodies are usually measured and X-rays often taken as part of diagnosis. When this has not been done, the committee agreed that the tests should be performed as soon as possible. The results will inform discussions with the patient about how their rheumatoid arthritis might progress and reinforce the importance of active monitoring and rapidly seeking specialist care if the disease worsens.
There was limited evidence on poor function, as measured by the HAQ, as a prognostic factor. However, the committee agreed that functional ability (measured, for example, by HAQ) should be determined at diagnosis to provide a baseline for assessing response to treatment at the annual review.
Evidence suggests that all people with RA should be offered the same management strategy; however, in the committee's experience some people may respond less well and have more progressive radiographic damage and impaired function. Because the evidence was limited as to whether people with poor prognostic markers should follow a different management strategy to improve radiographic and functional (HAQ) outcomes, the committee agreed to make a research recommendation.

Impact

Anti-CCP antibodies are usually measured so there should be no change in current practice. X-raying the hands and feet and measuring functional ability at baseline reflects current best practice, but not everyone with rheumatoid arthritis currently has these investigations. There may be an increase in the number of X-rays, especially in units without early inflammatory arthritis clinics, but this is unlikely to have a substantial resource impact.
Measuring functional ability at baseline will involve a change of practice for some providers, but the cost is low and so this is not expected to have a substantial resource impact.
Full details of the evidence and the committee's discussion are in evidence review B: Risk factors.

Rationale and impact: treat-to-target strategy

Rationale

Strategy and treatment target
Evidence showed that a treat-to-target strategy was more effective than usual care for managing rheumatoid arthritis and improved outcomes at no additional cost. The committee agreed that this approach was more likely to achieve rapid and sustained disease control.
No evidence was identified to indicate whether a target of remission or low disease activity was more effective. However, the committee agreed that remission (for example, a DAS28 score of less than 2.6) is the most appropriate target for most people, but for some who are unable to achieve remission despite a treat-to-target approach with appropriate escalation, low disease activity (for example, a DAS28 score of less than 3.2) is acceptable. It was agreed that for those identified as being at risk of poor prognosis, a target of remission may be more appropriate
Frequency of monitoring for active disease
No studies were identified that compared different frequencies of monitoring specifically in people with active disease. The committee noted that the 2009 guideline recommended monthly monitoring and that this was used in some of the studies of a treat-to-target strategy. The committee agreed that monthly monitoring of C-reactive protein and disease activity was most appropriate for active disease. This allows dose escalation of DMARDs, checking the need for short-term bridging treatment with glucocorticoids and whether people are tolerating the drug regimen, assessing side effects, providing support and encouraging adherence.
People at risk of poor outcomes
There was no evidence that people with a poor prognosis should have different management in terms of the treatment target or the frequency of monitoring. However, in the committee's experience rheumatoid arthritis often responds less well to standard management in this group. The committee agreed that the recommendations on treat-to-target with monthly monitoring should ensure that people with a poor prognosis receive effective treatment, but they decided to make a research recommendation to inform future guidance for managing rheumatoid arthritis in this group.

Impact

A treat-to-target strategy is current best practice in most NHS settings. The 2016 National Clinical Audit for Rheumatoid Arthritis and Early Inflammatory Arthritis indicated that healthcare professionals set a treatment target for about 90% of their patients. Although the 2018 recommendation specifies a target of remission or low disease activity, rather than a disease level previously agreed with the person, the committee agreed that these are the targets commonly used and so this is unlikely to involve a significant change in practice.
Monthly monitoring was recommended in the 2009 guideline, but the committee acknowledged that many clinics do not monitor active disease this often. A regional survey (Tugnet 2013) reported that about two-thirds of people with rheumatoid arthritis received monthly C-reactive protein monitoring but only a quarter had monthly monitoring of disease activity (with about 40% in dedicated early arthritis clinics) until disease control was achieved. The committee were unsure whether these rates reflected practice across England and noted that practice had improved since the survey was conducted in 2011. However, the committee agreed that monthly monitoring would likely involve a change in practice in some clinics.
Full details of the evidence and the committee's discussion are in evidence review C: Treat-to-target.

Rationale and impact: cDMARDs

Rationale

First-line treatment
Evidence showed that starting treatment with more than 1 cDMARD was no more effective than starting with a single cDMARD. The committee agreed that cDMARD monotherapy might have fewer side effects and recommended cDMARD monotherapy as first-line treatment. This differed from the 2009 guideline which recommended combination therapy. The difference is largely a result of inclusion of different evidence and a different approach to analysing that evidence.
Many of the studies included in the 2009 guideline used cDMARDs that are no longer commonly used in UK practice (for example, ciclosporin), and these studies were excluded from the evidence for the 2018 update. In addition, the 2018 update included new evidence published after the 2009 guideline. Further, a different approach to analysing the evidence was taken, with the 2018 update aiming to identify the most effective cDMARD strategy (monotherapy, sequential monotherapy, step-up therapy, step-down therapy or parallel combination therapy) as well as which cDMARD should be used. The 2009 guideline compared treatment strategies only, regardless of the particular cDMARDs, and combined evidence according to treatment strategy.
The evidence included in the 2018 update was therefore different to that included in 2009 and supported cDMARD monotherapy as first-line treatment.
Evidence from randomised controlled trials in people who had never had a DMARD showed no consistent differences in the effectiveness of methotrexate, leflunomide and sulfasalazine as monotherapies. The drugs also had similar costs. The committee agreed that any of these drugs can be used as first-line treatment.
Hydroxychloroquine was less effective, but fewer people stopped treatment because of side effects. The committee agreed that hydroxychloroquine could be considered for people with mild or palindromic disease.
People at risk of poor outcomes
Evidence for different first-line treatment in people with a poor prognosis was limited so the committee decided not to make a separate recommendation for this group. They agreed that the recommendation for dose increases and treating to target (with the aim of keeping disease activity low) should ensure adequate treatment for these people. Given the limited evidence in this area, the committee also decided that the possible benefit of managing rheumatoid arthritis with a poor prognosis with a different strategy was a priority for future research.
Further treatment
Evidence supported adding another cDMARD when needed (step-up strategy) rather than replacing the cDMARD with another (sequential monotherapy). The committee acknowledged that more side effects were possible with a step-up strategy, but in their experience these could be managed by drug monitoring and were outweighed by the clinical benefit of combination treatment when monotherapy was inadequate. A published economic analysis supported a step-up approach rather than sequential monotherapy.
Subcutaneous methotrexate
No evidence was found for subcutaneous methotrexate, but the committee agreed that the effects may be superior and side effects fewer than with oral cDMARDs. However, because subcutaneous methotrexate is significantly more expensive than other cDMARD options, the committee was not able to recommend this without evidence of clinical benefit and cost effectiveness relative to oral cDMARDs. The committee decided to make a research recommendation to inform future guidance.

Impact

The 2009 guideline recommended a combination of cDMARDs (including methotrexate and at least 1 other cDMARD) for newly diagnosed rheumatoid arthritis and emphasised the importance of starting effective cDMARD therapy as soon as possible.
The 2009 recommendation to start with combination therapy was not widely adopted. The 2016 National Clinical Audit for Rheumatoid Arthritis and Early Inflammatory Arthritis reported that only 46% of people with rheumatoid arthritis received combination cDMARDs at any time. Currently there is variation in practice regarding the choice of cDMARD(s) and treatment strategy, with many healthcare professionals preferring to start with monotherapy and only use combination therapy when response is inadequate.
The 2018 recommendations to start with monotherapy and add drugs when the response is inadequate are unlikely to have a substantial impact on practice or resources, as they align with the current approach taken by many healthcare professionals. However, the recommendations should result in a more consistent treatment strategy and reduce the number of people prescribed combination therapy on diagnosis.
The 2009 guideline recommended methotrexate as one of the first drugs used in combination therapy. The 2018 recommendations do not specify which cDMARD should be used at any stage of treatment. Again, this will be unlikely to have a significant impact on practice, and methotrexate is likely to remain one of the most commonly prescribed drugs.
The recommendations on dose escalation and reduction have not changed substantially from the 2009 guideline and reflect current clinical practice. The committee clarified that dose reduction and the use of a step-down strategy should only be considered after a person has maintained the treatment target for at least 1 year without the use of glucocorticoids.
Full details of the evidence and the committee's discussion are in evidence review F: DMARDs.

Rationale and impact: short-term bridging treatment with glucocorticoids

Rationale

Evidence from randomised controlled trials on the use of short-term bridging treatment with glucocorticoids to relieve symptoms while people are waiting for a new DMARD to take effect was limited. There was some evidence that fewer people withdrew from the studies due to inefficacy or adverse events when they were taking glucocorticoids, although there was no evidence that glucocorticoids were effective in terms of disease activity score, quality of life or function, as studies did not report these outcomes. In the committee's experience people with active arthritis may benefit from the anti-inflammatory effects of glucocorticoids. However, for others with less active disease this additional treatment may not be needed. The committee agreed that short-term glucocorticoids could be considered on a case-by-case basis.
Because of the lack of good quality evidence, the committee decided to make a research recommendation to determine the effectiveness of short-term glucocorticoids for adults taking a new DMARD, including the most effective regimen.

Impact

Most healthcare professionals offer short-term bridging treatment with glucocorticoids to adults starting a new DMARD. They can continue to offer this but the recommendation encourages them to consider whether this additional treatment is always needed. Therefore this is unlikely to result in additional spending for the NHS.
Full details of the evidence and the committee's discussion are in evidence review H: Glucocorticoids.

Rationale and impact: symptom control

Rationale

Evidence suggested that NSAIDs may offer a small benefit in relieving symptoms for adults with rheumatoid arthritis (including pain and stiffness). The committee agreed that this was likely to outweigh the increase in gastrointestinal adverse events associated with NSAIDs. To minimise adverse events, the committee agreed that NSAIDs should be used at the lowest doses and for the shortest possible time, with a PPI, and that risk factors for adverse events should be reviewed regularly.
There was limited evidence on paracetamol, opioids and tricyclic antidepressants and no evidence for nefopam, gabapentinoids or selective serotonin reuptake inhibitor (SSRI) and SSNRI antidepressants. The committee acknowledged that the 2009 guideline had recommended analgesics other than NSAIDs for pain control. However, the 2009 guideline indicated that the evidence on analgesia other than NSAIDs was 'sparse'. No further evidence on these drugs was identified since the publication of the 2009 guideline. The committee for the 2018 guideline decided to make a research recommendation rather than a practice recommendation on analgesia other than NSAIDs.

Impact

Current practice regarding the choice of analgesic is variable, with paracetamol, compound analgesics and NSAIDs all commonly used to control symptoms. Choice of analgesic tends to be based on individual effectiveness as well as the person's risk profile, tolerance, and side effects. In particular, there are some groups of people for whom NSAIDs are unsuitable because of contraindications, comorbidities or tolerability, and other people who are currently benefiting from analgesic drugs other than NSAIDs. The current approach is likely to continue but there may be an increase in prescribing of NSAIDs instead of other analgesic drugs for people with newly diagnosed rheumatoid arthritis.
Full details of the evidence and the committee's discussion are in evidence review G: Analgesics.

Rationale and impact: monitoring

Rationale

Frequency of monitoring when treatment target has been achieved
No evidence was identified on monitoring frequency once the treatment target has been achieved. However, the committee agreed that once people with RA had achieved the treatment target, and this was sustained at a 6-month follow-up appointment, there was no need for additional routine appointments to be scheduled other than the annual reivew. All people with RA should have an annual review.
In people with established rheumatoid arthritis (rheumatoid arthritis for at least 2 years), the evidence suggested that patient-initiated rapid access and scheduled medical review every 3 to 6 months were similarly effective. The committee agreed that all adults with rheumatoid arthritis should have rapid access to specialist care for disease flares, and ongoing drug monitoring.
Ultrasound in monitoring
Randomised controlled evidence did not support using ultrasound for routine monitoring of rheumatoid arthritis. However, in the committee's experience ultrasound can be useful for monitoring when clinical examination is inconclusive or is inconsistent with other signs of disease activity (for example, pain or markers of inflammation). The committee decided to make a research recommendation to inform future guidance about using ultrasound in these situations.

Impact

The frequency of monitoring and review appointments for people who have reached the treatment target vary around the country, with some people being seen more often than needed and others not receiving adequate follow-up. The 2018 recommendations are likely to reduce unwarranted variation.
Most people with rheumatoid arthritis currently have rapid access to specialist care when they have a flare. The 2016 National Clinical Audit for Rheumatoid Arthritis and Early Inflammatory Arthritis reported that 92% of people had access to urgent advice, with 97% of providers running a telephone advice line. Therefore the recommendation will not affect current practice.
Use and availability of ultrasound varies widely across the country and even between healthcare professionals in the same department. Some healthcare professionals use it routinely whereas others use it on a case-by-case basis. The recommendation should reduce the overall use of ultrasound while still allowing its use for selected subgroups.
Full details of the evidence and the committee's discussion are in evidence review E: Frequency of monitoring.

Glossary

(glucocorticoids used for a short period of time when a person is starting a new DMARD, intended to improve symptoms while waiting for the new DMARD to take effect (which can take 2 to 3 months))
cyclic citrullinated peptide
(conventional disease-modifying anti-rheumatic drug: synthetic drugs that modify disease rather than just alleviating symptoms; they include methotrexate, sulfasalazine, leflunomide and hydroxychloroquine, but do not include biological DMARDs and targeted synthetic DMARDs)
disease activity score
disease-modifying anti-rheumatic drug
disease-modifying anti-rheumatic drugs
European League Against Rheumatism
Health Assessment Questionnaire
non-steroidal anti-inflammatory drugs
(inflammatory arthritis that causes attacks of joint pain and swelling similar to rheumatoid arthritis; between attacks the joints return to normal)
proton pump inhibitor
(during treatment with 2 or more DMARDs, tapering and stopping at least 1 drug once disease is adequately controlled)
(additional DMARDs are added to DMARD monotherapy when disease is not adequately controlled)
(soft tissue joint swelling)
transcutaneous electrical nerve stimulators
tumour necrosis factor
(a strategy that defines a treatment target (such as remission or low disease activity) and applies tight control (for example, monthly visits and respective treatment adjustment) to reach this target; the treatment strategy often follows a protocol for treatment adaptations depending on the disease activity level and degree of response to treatment)

Paths in this pathway

Pathway created: April 2013 Last updated: August 2020

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