Recommendations

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.

1.1 Referral, diagnosis and investigations

Referral from primary care

1.1.1 Refer for specialist opinion any adult with suspected persistent synovitis of undetermined cause. Refer urgently (even with a normal acute-phase response, negative anti-cyclic citrullinated peptide [CCP] antibodies or rheumatoid factor) if any of the following apply:

  • the small joints of the hands or feet are affected

  • more than one joint is affected

  • there has been a delay of 3 months or longer between onset of symptoms and seeking medical advice. [2009, amended 2018]

Investigations

If the following investigations are ordered in primary care, they should not delay referral for specialist opinion (see recommendation 1.1.1).

Investigations for diagnosis

1.1.2 Offer to carry out a blood test for rheumatoid factor in adults with suspected rheumatoid arthritis (RA) who are found to have synovitis on clinical examination. [2009]

1.1.3 Consider measuring anti-CCP antibodies in adults with suspected RA if they are negative for rheumatoid factor. [2009, amended 2018]

1.1.4 X-ray the hands and feet in adults with suspected RA and persistent synovitis. [2009, amended 2018]

Investigations following diagnosis

1.1.5 As soon as possible after establishing a diagnosis of RA:

  • measure anti-CCP antibodies, unless already measured to inform diagnosis

  • X-ray the hands and feet to establish whether erosions are present, unless X-rays were performed to inform diagnosis

  • measure functional ability using, for example, the Health Assessment Questionnaire (HAQ), to provide a baseline for assessing the functional response to treatment. [2018]

1.1.6 If anti-CCP antibodies are present or there are erosions on X-ray:

  • advise the person that they have an increased risk of radiological progression but not necessarily an increased risk of poor function, and

  • emphasise the importance of monitoring their condition, and seeking rapid access to specialist care if disease worsens or they have a flare. [2018]

To find out why the committee made the 2018 recommendations on investigations following diagnosis and how they might affect practice, see rationale and impact.

1.2 Treat-to-target strategy

1.2.1 Treat active RA in adults with the aim of achieving a target of remission or low disease activity if remission cannot be achieved (treat-to-target). [2018]

1.2.2 Consider making the target remission rather than low disease activity for people with an increased risk of radiological progression (presence of anti-CCP antibodies or erosions on X-ray at baseline assessment). [2018]

1.2.3 In adults with active RA, measure C-reactive protein (CRP) and disease activity (using a composite score such as DAS28) monthly in specialist care until the target of remission or low disease activity is achieved. [2018]

To find out why the committee made the 2018 recommendations on treat-to-target strategy and how they might affect practice, see rationale and impact.

1.3 Communication and education

1.3.1 Explain the risks and benefits of treatment options to adults with RA in ways that can be easily understood. Throughout the course of their disease, offer them the opportunity to talk about and agree all aspects of their care, and respect the decisions they make. [2009]

1.3.2 Offer verbal and written information to adults with RA to:

  • improve their understanding of the condition and its management, and

  • counter any misconceptions they may have. [2009]

1.3.3 Adults with RA who wish to know more about their disease and its management should be offered the opportunity to take part in existing educational activities, including self-management programmes. [2009]

1.4 Initial pharmacological management

Conventional disease-modifying anti-rheumatic drugs

1.4.1 For adults with newly diagnosed active RA:

  • Offer first-line treatment with conventional disease-modifying anti-rheumatic drug (cDMARD) monotherapy using oral methotrexate, leflunomide or sulfasalazine as soon as possible and ideally within 3 months of onset of persistent symptoms.

  • Consider hydroxychloroquine for first-line treatment as an alternative to oral methotrexate, leflunomide or sulfasalazine for mild or palindromic disease.

  • Escalate dose as tolerated. [2018]

1.4.2 Consider short-term bridging treatment with glucocorticoids (oral, intramuscular or intra-articular) when starting a new cDMARD. [2018]

To find out why the committee made the 2018 recommendation on short-term bridging treatment with glucocorticoids and how it might affect practice, see rationale and impact.

1.4.3 Offer additional cDMARDs (oral methotrexate, leflunomide, sulfasalazine or hydroxychloroquine) in combination in a step-up strategy when the treatment target (remission or low disease activity) has not been achieved despite dose escalation. [2018]

To find out why the committee made the 2018 recommendations on cDMARDs and how they might affect practice, see rationale and impact.

1.5 Further pharmacological management

Biological and targeted synthetic DMARDs

NICE has published technology appraisal guidance on biological and targeted synthetic DMARDs for RA. For full details, see our interactive flowchart on rheumatoid arthritis.

The recommendations below are from NICE technology appraisal guidance 72. The 2009 guideline committee reviewed the evidence on anakinra and incorporated the recommendations into the guideline. The technology appraisal was then withdrawn.

1.5.1 On the balance of its clinical benefits and cost effectiveness, anakinra is not recommended for the treatment of RA, except in the context of a controlled, long-term clinical study. [2009]

1.5.2 Patients currently receiving anakinra for RA may suffer loss of wellbeing if their treatment were discontinued at a time they did not anticipate. Therefore, patients should continue therapy with anakinra until they and their consultant consider it is appropriate to stop. [2009]

1.5.3 Do not offer the combination of tumour necrosis factor-α (TNF-α) inhibitor therapy and anakinra for RA. [2009]

Glucocorticoids

1.5.4 Offer short-term treatment with glucocorticoids for managing flares in adults with recent-onset or established disease to rapidly decrease inflammation. [2009]

1.5.5 In adults with established RA, only continue long-term treatment with glucocorticoids when:

  • the long-term complications of glucocorticoid therapy have been fully discussed, and

  • all other treatment options (including biological and targeted synthetic DMARDs) have been offered. [2009, amended 2018]

1.6 Symptom control

1.6.1 Consider oral non-steroidal anti-inflammatory drugs (NSAIDs, including traditional NSAIDs and cox II selective inhibitors), when control of pain or stiffness is inadequate. Take account of potential gastrointestinal, liver and cardio-renal toxicity, and the person's risk factors, including age and pregnancy. [2018]

1.6.2 When treating symptoms of RA with oral NSAIDs:

  • offer the lowest effective dose for the shortest possible time

  • offer a proton pump inhibitor (PPI), and

  • review risk factors for adverse events regularly. [2018]

1.6.3 If a person with RA needs to take low-dose aspirin, healthcare professionals should consider other treatments before adding an NSAID (with a PPI) if pain relief is ineffective or insufficient. [2009, amended 2018]

To find out why the committee made the 2018 recommendations on symptom control and how they might affect practice, see rationale and impact.

1.7 The multidisciplinary team

1.7.1 Adults with RA should have ongoing access to a multidisciplinary team. This should provide the opportunity for periodic assessments (see 1.9.2 and 1.9.3) of the effect of the disease on their lives (such as pain, fatigue, everyday activities, mobility, ability to work or take part in social or leisure activities, quality of life, mood, impact on sexual relationships) and help to manage the condition. [2009]

1.7.2 Adults with RA should have access to a named member of the multidisciplinary team (for example, the specialist nurse) who is responsible for coordinating their care. [2009]

1.8 Non-pharmacological management

Physiotherapy

1.8.1 Adults with RA should have access to specialist physiotherapy, with periodic review (see 1.9.2 and 1.9.3), to:

  • improve general fitness and encourage regular exercise

  • learn exercises for enhancing joint flexibility, muscle strength and managing other functional impairments

  • learn about the short-term pain relief provided by methods such as transcutaneous electrical nerve stimulators (TENS) and wax baths. [2009]

Occupational therapy

1.8.2 Adults with RA should have access to specialist occupational therapy, with periodic review (see 1.9.2 and 1.9.3), if they have:

  • difficulties with any of their everyday activities, or

  • problems with hand function. [2009]

Hand exercise programmes

1.8.3 Consider a tailored strengthening and stretching hand exercise programme for adults with RA with pain and dysfunction of the hands or wrists if:

  • they are not on a drug regimen for RA, or

  • they have been on a stable drug regimen for RA for at least 3 months. [2015]

1.8.4 The tailored hand exercise programme for adults with RA should be delivered by a practitioner with training and skills in this area. [2015]

Podiatry

1.8.5 All adults with RA and foot problems should have access to a podiatrist for assessment and periodic review of their foot health needs (see 1.9.2 and 1.9.3). [2009]

1.8.6 Functional insoles and therapeutic footwear should be available for all adults with RA if indicated. [2009]

Psychological interventions

1.8.7 Offer psychological interventions (for example, relaxation, stress management and cognitive coping skills[1]) to help adults with RA adjust to living with their condition. [2009]

NICE has published a guideline on depression in adults with a chronic physical health problem.

Diet and complementary therapies

1.8.8 Inform adults with RA who wish to experiment with their diet that there is no strong evidence that their arthritis will benefit. However, they could be encouraged to follow the principles of a Mediterranean diet (more bread, fruit, vegetables and fish; less meat; and replace butter and cheese with products based on vegetable and plant oils). [2009]

1.8.9 Inform adults with RA who wish to try complementary therapies that although some may provide short-term symptomatic benefit, there is little or no evidence for their long-term efficacy. [2009]

1.8.10 If an adult with RA decides to try complementary therapies, advise them:

  • these approaches should not replace conventional treatment

  • this should not prejudice the attitudes of members of the multidisciplinary team, or affect the care offered. [2009]

1.9 Monitoring

1.9.1 Ensure that all adults with RA have:

  • rapid access to specialist care for flares

  • information about when and how to access specialist care, and

  • ongoing drug monitoring. [2018]

1.9.2 Consider a review appointment to take place 6 months after achieving treatment target (remission or low disease activity) to ensure that the target has been maintained. [2018]

1.9.3 Offer all adults with RA, including those who have achieved the treatment target, an annual review to:

  • assess disease activity and damage, and measure functional ability (using, for example, the Health Assessment Questionnaire [HAQ])

  • check for the development of comorbidities, such as hypertension, ischaemic heart disease, osteoporosis and depression

  • assess symptoms that suggest complications, such as vasculitis and disease of the cervical spine, lung or eyes

  • organise appropriate cross referral within the multidisciplinary team

  • assess the need for referral for surgery (see section 1.10)

  • assess the effect the disease is having on a person's life. [2009, amended 2018]

1.9.4 For adults who have maintained the treatment target (remission or low disease activity) for at least 1 year without glucocorticoids, consider cautiously reducing drug doses or stopping drugs in a step-down strategy. Return promptly to the previous DMARD regimen if the treatment target is no longer met. [2018]

1.9.5 Do not use ultrasound for routine monitoring of disease activity in adults with RA. [2018]

To find out why the committee made the 2018 recommendations on monitoring and how they might affect practice, see rationale and impact.

1.10 Timing and referral for surgery

1.10.1 Offer to refer adults with RA for an early specialist surgical opinion if any of the following do not respond to optimal non-surgical management:

  • persistent pain due to joint damage or other identifiable soft tissue cause

  • worsening joint function

  • progressive deformity

  • persistent localised synovitis. [2009]

1.10.2 Offer to refer adults with any of the following complications for a specialist surgical opinion before damage or deformity becomes irreversible:

  • imminent or actual tendon rupture

  • nerve compression (for example, carpal tunnel syndrome)

  • stress fracture. [2009]

1.10.3 When surgery is offered to adults with RA, explain that the main[2] expected benefits are:

  • pain relief

  • improvement, or prevention of further deterioration, of joint function, and

  • prevention of deformity. [2009]

1.10.4 Offer urgent combined medical and surgical management to adults with RA who have suspected or proven septic arthritis (especially in a prosthetic joint). [2009]

1.10.5 If an adult with RA develops any symptoms or signs that suggest cervical myelopathy[3]:

  • request an urgent MRI scan, and

  • refer for a specialist surgical opinion. [2009]

1.10.6 Do not let concerns about the long-term durability of prosthetic joints influence decisions to offer joint replacements to younger adults with RA. [2009]

Terms used in this guideline

Bridging treatment

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).

Conventional disease-modifying anti-rheumatic drug (cDMARD)

Conventional disease-modifying anti-rheumatic drugs are 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.

Palindromic

Palindromic rheumatism is an inflammatory arthritis that causes attacks of joint pain and swelling similar to RA. Between attacks the joints return to normal.

Step-up strategy

Additional DMARDs are added to DMARD monotherapy when disease is not adequately controlled.

Step-down strategy

During treatment with 2 or more DMARDs, tapering and stopping at least 1 drug once disease is adequately controlled.

Synovitis

Soft tissue joint swelling.

Treat-to-target

A treat-to-target strategy is 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.



[1] Such as managing negative thinking.

[2] Cosmetic improvements should not be the dominant concern.

[3] For example, paraesthesia, weakness, unsteadiness, reduced power, extensor plantars.

  • National Institute for Health and Care Excellence (NICE)