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Rheumatoid arthritis

About

What is covered

This interactive flowchart covers the diagnosis and management of rheumatoid arthritis in adults.

Updates

Updates to this interactive flowchart

10 July 2018 Full update on publication of rheumatoid arthritis in adults: management (NICE guideline NG100).
7 November 2017 Total distal radioulnar joint replacement for symptomatic joint instability or arthritis (NICE interventional procedures guidance 595) added to surgical treatment.
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.
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 diagnosis and management of rheumatoid arthritis in adults.

Updates

Updates to this interactive flowchart

10 July 2018 Full update on publication of rheumatoid arthritis in adults: management (NICE guideline NG100).
7 November 2017 Total distal radioulnar joint replacement for symptomatic joint instability or arthritis (NICE interventional procedures guidance 595) added to surgical treatment.
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.
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 (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
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 updated 2018) 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.

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 guidance

Rheumatoid arthritis in adults: management (2018) NICE guideline NG100, recommendation 1.1.1

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.

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 guidance

Rheumatoid arthritis in adults: management (2018) NICE guideline NG100, recommendation 1.1.1

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 conventional disease-modifying anti-rheumatic drug (cDMARD) monotherapy within 3 months of onset of persistent symptoms.

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. Because the effects of cDMARD monotherapy are not experienced straight away, healthcare professionals should consider using short-term bridging treatment with glucocorticoids to relieve symptoms while people are waiting for the cDMARD to take effect.

Quality measure

Structure
Evidence of local arrangements for people with newly diagnosed rheumatoid arthritis to receive cDMARD monotherapy within 3 months of onset of persistent symptoms.
Process
Proportion of people with newly diagnosed rheumatoid arthritis who receive cDMARD monotherapy within 3 months of onset of persistent symptoms.
Numerator – the number of people in the denominator who receive cDMARD monotherapy within 3 months of onset of persistent symptoms.
Denominator – the number of people with newly diagnosed rheumatoid arthritis.

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 cDMARD monotherapy within 3 months of onset of persistent symptoms. They also ensure that using short-term bridging treatment with glucocorticoids is considered to relieve symptoms while people are waiting for the cDMARD to take effect.
Healthcare professionals ensure that people with newly diagnosed rheumatoid arthritis are offered cDMARD monotherapy within 3 months of onset of persistent symptoms. They also consider offering short-term bridging treatment with glucocorticoids to relieve symptoms while people are waiting for the cDMARD to take effect.
Commissioners ensure they commission services that enable people with newly diagnosed rheumatoid arthritis to be offered cDMARD monotherapy within 3 months of onset of persistent symptoms. They also ensure that short-term bridging treatment with glucocorticoids is available to relieve symptoms while people are waiting for the cDMARD to take effect.
People with newly diagnosed rheumatoid arthritis are offered a drug called a cDMARD by a rheumatology service within 3 months of persistent symptoms starting.

Source guidance

Rheumatoid arthritis in adults: management (2018) NICE guideline NG100, recommendation 1.4.1

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 with a cDMARD should be offered as the first-line treatment. When starting the new cDMARD, short-term bridging treatment with glucocorticoids should also be considered. An additional cDMARD should be offered in combination in a step-up strategy when the treatment target (remission or low disease activity) has not been achieved despite dose escalation.
People receiving treatment with cDMARD 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.

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 guidance

Rheumatoid arthritis in adults: management (2018) NICE guideline NG100, recommendation 1.3.3

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 have their C-reactive protein (CRP) and disease activity measured monthly in specialist care until they are in remission or have low disease activity.

Rationale

Regular monitoring of CRP and disease activity allows for dose escalation of disease-modifying anti-rheumatic drugs (DMARDs). It is also important for checking the need for short-term bridging treatment with glucocorticoids and whether people are tolerating the drug regimen, assessing for side effects, providing support and encouraging adherence.

Quality measure

Structure
Evidence of local arrangements to ensure that people with active rheumatoid arthritis have their CRP and disease activity measured monthly in specialist care until they are in remission or have low disease activity.
Process
a) Proportion of people with active rheumatoid arthritis who have their CRP and disease activity measured monthly.
Numerator – the number of people in the denominator who have their CRP and disease activity measured monthly.
Denominator – the number of people with active rheumatoid arthritis.
b) Proportion of people with previously active rheumatoid arthritis, who had their CRP and disease activity measured monthly in specialist care until they were in remission or had low disease activity.
Numerator – the number of people in the denominator who had their CRP and disease activity measured monthly in specialist care until they were in remission or had low disease activity.
Denominator – the number of people with previously active rheumatoid arthritis, who are currently in remission or have low disease activity.
Outcome
a) Controlled rheumatoid arthritis.
b) Functional ability.

What the quality statement means for each audience

Service providers ensure systems are in place for people with active rheumatoid arthritis to have their CRP and disease activity measured monthly in specialist care until they are in remission or have low disease activity.
Healthcare professionals ensure that people with active rheumatoid arthritis have their CRP and disease activity measured monthly in specialist care until they are in remission or have low disease activity.
Commissioners ensure they commission services that enable people with active rheumatoid arthritis to have their CRP and disease activity measured monthly in specialist care until they are in remission or have low disease activity.
People with active rheumatoid arthritis have their disease activity monitored every month in specialist care until they are in remission or have low disease activity.

Source guidance

Rheumatoid arthritis in adults: management (2018) NICE guideline NG100, recommendation 1.2.3

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

Remission (for example, a DAS28 score of less than 2.6) is the most appropriate target for most people. For those 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 an acceptable target.

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.

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 guidance

Rheumatoid arthritis in adults: management (2018) NICE guideline NG100, recommendation 1.9.1

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.

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 guidance

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

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 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.

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 cost 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
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: July 2018

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