RHEUMATOLOGY
Rheumatoid arthritis in adults:
updated NICE guidelines
What are the implications of the 2018 updated NICE guidelines on rheumatoid arthritis
for commissioners and providers of services for these patients?
Frank McKenna
BA MD FRCP
Consultant Physician
and Rheumatologist
Manchester University
Foundation Trust, UK;
(Clinical Lead for the
guideline revision)
In July 2018, the National Institute for Health
and Care Excellence (NICE) published revised
guidelines for the management of rheumatoid
arthritis (RA) disease in adults. 1 Some clinicians
will find it challenging to adhere to these,
but they reflect best practice. Management
of rheumatoid arthritis depends on a
multidisciplinary approach and shared care
between secondary and primary care. The
guideline is relevant to non-specialist health
professionals who are involved in the initial
assessment of RA symptoms and ongoing care
of people diagnosed with RA. What are the
implications of these guidelines for
commissioners and providers of services
for people with RA?
The condition
RA is a chronic, disabling autoimmune disease
characterised by synovitis of small and large
joints causing swelling, stiffness, pain, and
progressive joint destruction. Approximately 1%
of the UK population have RA, and as many as
15% of these people may have severe active
disease at any point in time. It affects roughly
three times as many women as men. People tend
to develop RA between 40 and 60 years of age,
although it can occur at any age. The early signs
of rheumatoid arthritis of joint pain and swelling
usually present in primary care. Fast and accurate
referral to rheumatology services is important to
achieve early remission and prevent or reduce
disability. 2
Why do we need another NICE guideline
on RA?
The management of RA has evolved in the nine
years since the previous NICE guideline on RA
was published, with greater emphasis on a
treat-to-target strategy rather than specific drug
regimens, 3 and debate about the merit of
initiating treatment with combination drug
therapy. 4 Technologies such as ultrasound have
been increasingly used for diagnosis and
monitoring of synovitis where it is unclear from
clinical examination. 5 These aspects of
management were investigated by the Guideline
Committee, and recommendations have been
updated using new evidence, leading to changes
to the recommendations for treatment with
conventional synthetic disease modifying
anti-rheumatic drugs (csDMARDs), glucocorticoids
for bridging treatment, and choice of treatment
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HHE 2019 | hospitalhealthcare.com
for symptom control. Several aspects of the
guideline have remained unchanged since its
publication in 2009.
NICE publishes evidence-based
recommendations for health and care in England
(not Wales or Scotland, although they can also be
used there). The express aim of the Institute is to
prevent ill health, to promote and protect good
health, to improve the quality of care and services
and to adapt and provide health and social care
services. The guidelines are widely used to define
‘minimum standards of care’ in the UK, so that
patients and carers using the National Health
Service (NHS) know what they are entitled to
receive from healthcare providers. Commissioners
and Trusts are expected to adhere to NICE
guidelines and to assure the process through
regular audit. If this does not happen, then
providers would be open to censure, for example
by the Health Service Ombudsman in the event of
a complaint, and may lose their eligibility to bid
for provision of specialised services.
Service quality
NICE also publishes quality standards in the form
of statements that are designed for
commissioners and providers to identify gaps
in service provision and areas for improvement,
to facilitate measurement of quality of care and
demonstration of high quality care, with the aim
to facilitate commissioning of high quality
services. The Quality standards for RA were last
published in 2013 but are currently being
revised. Clinicians would normally be expected to
undertake regular audit against these standards,
and commissioners might be expected to receive
assurance that this is undertaken.
What’s new in this guideline?
The new recommendations are:
• Rapid referral based on clinical examination
alone
• Treat to target of remission or low disease
activity
• csDMARD monotherapy then step up
combination
• Encourage steroid bridging therapy.
Referral
The guideline emphasises the importance of rapid
referral to a rheumatologist for any adult with
suspected persistent synovitis of undetermined
cause independent of investigations including