2 Clinical need and practice
2.1 Rheumatoid arthritis is a systemic chronic inflammatory autoimmune disease that typically affects synovial joints (such as those in the hands and feet), causing swelling, stiffness, pain and progressive irreversible joint destruction. Disease can also occur outside the joints, affecting other organs, including the lungs, heart and eyes. Rheumatoid arthritis is associated with increased mortality and increasing disability, which has a severe effect on quality of life. It is associated with substantial costs; direct costs of drug acquisition and hospitalisation and indirect costs of reduced productivity.
2.2 There are estimated to be around 400,000 people with rheumatoid arthritis in the UK. Of these, approximately 15% have severe disease. It is about 2–4 times more prevalent in women than in men. It can develop at any age, but the peak age of onset in the UK is about 40–70 years.
2.3 There is no cure for rheumatoid arthritis. In early disease, management aims to suppress disease activity and induce remission, prevent loss of function, control joint damage, control pain and enhance self‑management. In established disease, management should address complications and associated comorbidity, as well as the effect of the condition on the person's quality of life.
2.4 Treatment for rheumatoid arthritis usually includes non‑steroidal anti‑inflammatory drugs (NSAIDs) or COX‑2 inhibitors, which reduce pain, fever, and joint swelling and inflammation, and disease‑modifying antirheumatic drugs (DMARDs). DMARDs slow the disease process and reduce joint damage. DMARDs can include drugs such as methotrexate, leflunomide and sulfasalazine (referred to as conventional DMARDs). Also available are a group of drugs including monoclonal antibodies and soluble receptors that modify the disease process by blocking key protein messenger molecules (such as cytokines) or cells (such as B‑lymphocytes). Such drugs are referred to as biological DMARDs. For some people their disease may not respond to DMARDs and for others the response to DMARDs often reduces over time. Therefore people need a sequence of treatments. Glucocorticoids are also used to control inflammation.
2.5 For people with newly diagnosed rheumatoid arthritis, the NICE guideline on rheumatoid arthritis recommends a combination of conventional DMARDs (including methotrexate and at least 1 other conventional DMARD, plus short‑term glucocorticoids) as first‑line treatment, ideally beginning within 3 months of the onset of persistent symptoms. When combination therapies are not appropriate, conventional DMARD monotherapy is used.
2.6 Measures of response to treatment include the American College of Rheumatology (ACR) response criteria (ACR20, 50 and 70). These require a specified improvement in tender joint count, swollen joint count, global assessments, pain, disability and an acute‑phase reactant (for example, erythrocyte sedimentation rate or C‑reactive protein). The disease activity score (DAS28) is an alternative scoring system that has been developed in Europe. It is calculated using a formula that includes counts for tender and swollen joints, an evaluation of general health by the person (on a scale of 0–100), and erythrocyte sedimentation rate or C‑reactive protein. A DAS28 greater than 5.1 indicates high disease activity, between 3.2 and 5.1 moderate disease activity, and less than 3.2 low disease activity. A score of less than 2.6 indicates disease remission. The European League Against Rheumatism (EULAR) response criteria use the degree of change in DAS28 and the DAS28 reached to determine good, moderate or non‑response. The Stanford Health Assessment Questionnaire (HAQ) is 1 component of the ACR criteria and scores physical disability and pain from 0 (least disability) to 3 (most severe disability).