Quality statement 3: Starting treatment

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.