their target was met. However, although this may
have resource implications the recommendation
remains that all patients should be reviewed
monthly in their rheumatology unit until they are
in remission or low disease state. Thereafter it is
recommended that patients should have a review
appointment after six months to ensure that the
target has been maintained and if stable to be
reviewed at least on an annual basis. The annual
review should be a comprehensive evaluation and
include an assessment of disease activity and
damage and any need for surgery, a measure of
functional ability (using, for example, the Health
Assessment Questionnaire) and impact on life,
a check for the development of comorbidities,
such as hypertension, ischaemic heart disease,
osteoporosis and depression, an assessment of
symptoms that suggest
complications such as
vasculitis and disease of
the cervical spine, lung
or eyes, and appropriate
Following patients monthly until
cross-referral within the
they reach a target of remission
multidisciplinary team.
An annual review was
or low disease activity should be
also included in the
standard
practice in secondary care
previous guideline but
many rheumatologists
have found a comprehensive review to be difficult
to deliver. The availability of specialist nurses is
often instrumental in supporting these
recommendations and service planning should
consider the resources required to deliver both
monthly monitoring and annual review. Although
labour intensive, this approach may prove cost
effective by reducing the number of patients who
need to be prescribed a bDMARD.
Corticosteroids
One problem with csDMARDS is that they have
a gradual onset of action over weeks to months.
In order to provide a rapid reduction in
symptoms, most rheumatologists recommend
short term bridging treatment with
glucocorticoids (oral, intramuscular, or intra-
articular). The guideline committee were unable
to strengthen the recommendation and advise
all patients to receive bridging therapy because
of the lack of research evidence. However,
rheumatologists should be encouraged to
prescribe short term steroids when initiating or
changing a DMARD and also for disease flares.
The guideline recommendation is to “Consider
short term bridging treatment with
glucocorticoids (oral, intramuscular, or intra-
articular) when starting a new conventional
synthetic DMARD.”
Symptom control
Although control of synovitis with csDMARD
and corticosteroids improves symptoms, some
patients require additional analgesia. The
committee found very limited evidence for
paracetamol, opioids, and tricyclic
antidepressants for symptom control in
rheumatoid arthritis, so the recommendation
for “other analgesics” was removed from the
update of this guideline and replaced with a
recommendation for NSAIDs alone – to consider
oral non-steroidal anti-inflammatory drugs
(NSAIDs), including traditional NSAIDs and Cox II
References
1 National Institute for Health
and Care Excellence. Rheumatoid
arthritis in adults: management:
NICE guideline (NG100).
July 2018. www.nice.org.uk/
guidance/ng100 (accessed
September 2019).
2 Kyburz D et al; physicians of
SCQM-RA. The long-term impact
of early treatment of rheumatoid
arthritis on radiographic
progression: a population-based
cohort study. Rheumatology
2011;50(6):1106–10.
3 Cohen MD, Keystone EC.
Rational therapy in RA: Issues
in implementing a treat-to-
target approach in RA. Nat Rev
Rheumatol 2013;9:137–8.
4 Sethi MK, O’Dell JR.
Combination conventional
DMARDs compared to
biologicals: what is the
evidence? Curr Opin Rheumatol
2015;27:183–8.
5 Lage-Hansen PR et al. The role
of ultrasound in diagnosing
rheumatoid arthritis, what do
we know? An updated review.
Rheumatol Int 2017;37:179–87.
23
HHE 2019 | hospitalhealthcare.com
selective inhibitors, when control of pain or
stiffness is inadequate taking account of potential
gastrointestinal, liver, and cardio-renal toxicity,
and the person’s risk factors, including age and
pregnancy. The lowest effective dose for the
shortest possible time of NSAIDs was
recommended with co-prescription of a proton
pump inhibitor and regular review of risk factors
for adverse events.
Monitoring
When patients with RA have met their target,
monitoring patients on DMARDs should be shared
between primary and secondary care. However,
flares of disease are characteristic of many
patients with RA and there should be rapid access
to specialist care for flares and this is emphasised
in the guideline. In addition, although the use of
ultrasound has expanded in rheumatology as well
as other specialties, the role of ultrasound in the
management of RA is unclear. 5 Following an
extensive literature review the conclusion in the
guideline was not to recommend ultrasonography
for routine monitoring of disease activity in
adults with RA.
Implementation
Some rheumatologists who have not adopted
a treat-to-target strategy may need a change
in practice. This will require revision of local
protocols in order that step-up protocols may be
implemented rather than initial combination
therapy. The recommendation to especially target
patients with poor prognostic markers will need
to be included in new protocols. In addition, there
may be challenges to health professionals in
primary and secondary care when explaining
risk factors for progression to some patients.
Ultrasound scanning of joints is increasing, and
the recommendation not to use ultrasound
routinely may need to be reflected in the revision
of local protocols.
Future research and guidelines
Although current evidence suggests that all
people with rheumatoid arthritis should be
offered the same management strategy, it is
possible that those identified with a risk of poor
prognosis should be treated differently. A high
priority research recommendation has been
included to answer this question. Research is also
needed to identify the best use of corticosteroids
in RA, and whether ultrasound can improve
management. In addition, In view of the
considerable difference in cost between
subcutaneous and oral methotrexate, further
research needs to be undertaken to determine
whether there is greater efficacy of subcutaneous
methotrexate compared with oral therapy.
Patients with a DAS28 between 3.2 and 5.1 are
often referred to as having moderate disease and
at present NICE do not have guidance for this
group of patients if they have failed csDMARDs;
they are not currently eligible for a bDMARD or
tsDAMRD unless they have a DAS28 >5.1. This has
proved difficult in managing these patients, but
with the reduction in costs of bDMARDs it is
hoped that revised health economic analyses will
find that it will be cost effective for those with
moderate disease to be treated with biosimilar
bDMARDs.