Recommendations for research

In 2009, the Guideline Development Group (GDG) made the following recommendations for research. The GDG's full set of research recommendations is detailed in the full guideline.

1 Diagnosis and investigations

How cost effective are MRI and ultrasound in establishing the diagnosis and prognosis of small joint synovitis?

How cost effective is the use of anti-CCP in establishing the diagnosis and prognosis of early inflammatory arthritis?

Why these are important

The sooner persistent synovitis is recognised and treated with DMARDs, the better the long-term outcome. In an aggressive acute-onset polyarthritis, the physical signs enable diagnosis. However, in other types of RA, the signs are not always obvious. Rheumatoid factor can be helpful both diagnostically and prognostically, but it is not as specific as anti-CCP antibodies. However, MRI and ultrasound are significantly more expensive than conventional radiology, particularly if new equipment needs to be purchased to provide this service. Testing for anti-CCP costs more than double testing for rheumatoid factor. It is important to determine the role of imaging and anti-CCP antibodies in early diagnosis and management decisions, and whether the added cost of these investigations is justified by better disease outcome, making these tests cost effective.

2 Pharmacological management of mild rheumatoid arthritis

The role of DMARDs in the treatment of mild RA should be assessed.

Why this is important

All trials of DMARDs have had active disease as an inclusion criterion. There has been no research on how to manage people with milder and less-active disease. Studies need to determine whether it would be safe/effective for people with mild disease to be observed over time without DMARD therapy, or with monotherapy, unless their disease becomes more aggressive. It may be that combination therapies are not appropriate for all people with mild RA.

3 Biological drugs in early rheumatoid arthritis

The cost effectiveness of early management with biological drugs (prior to the failure of two conventional DMARDs) should be assessed.

Why this is important

There is some evidence to suggest that if infliximab is introduced early in the course of the disease, a significant proportion of people can go into early and sustained remission, which can be maintained by conventional DMARDs alone. There is a need to determine whether this approach could be applied to other anti-TNF-α inhibitors, and if this approach is cost effective.

4 Symptom duration and patient outcomes

What is the effect of symptom duration on patient outcomes?

Why this is important

There is some evidence from the Finnish Rheumatoid Arthritis Combination Therapy (FinRACo) trial and other studies that suggests that symptom duration is a key determinant of outcomes in RA. However, this evidence is limited. This is very important in early RA management, so studies should look at the length of the 'window of opportunity' to intervene in RA, beyond which DMARDs are less likely to improve long-term outcomes.

5 Therapy after the failure of anti-TNF-α inhibitors

What is the most appropriate treatment strategy when the first TNF-α inhibitor fails?

Why this is important

If the first TNF-α inhibitor fails because of lack of or reduced efficacy, at the moment people with RA can only try rituximab or go back to conventional DMARDs. There is good evidence to suggest that biological drugs, including a second TNF-α inhibitor, are effective under these circumstances. Studies need to address whether other biological drugs should be considered in preference to rituximab for all people with RA, or certain subgroups, on the grounds of clinical and cost effectiveness.

  • National Institute for Health and Care Excellence (NICE)