July 2018: NICE has made new recommendations on treat-to-target strategy, initial pharmacological management, symptom control and monitoring. The recommendations and evidence in chapters 7 and 8 have been stood down and replaced.
There are over 400,000 people with rheumatoid arthritis (RA) in the UK. Although this makes it a common disorder, there are numerous other conditions ahead of it in terms of numbers, and indeed as causes of excess mortality. What this does not capture however, is the dreadful morbidity associated with the disease. The synovitis of RA affects multiple sites causing widespread pain, and the subsequent destruction of the joints can lead to severe disability affecting all aspects of motor function from walking to fine movements of the hand. Furthermore, RA is not simply a disease of the joints but can affect many other organs causing, for example, widespread vasculitis or severe lung fibrosis. More recently it has become apparent that RA is associated with an increased prevalence of coronary artery disease and significant increased risk of premature mortality.
Fortunately there are a considerable number of disease-modifying and anti-inflammatory agents which can significantly reduce the impact of RA. Some of these, for example corticosteroids, sulphasalazine or methotrexate, have been available for many years, and rheumatologists are well used to balancing the benefits and side-effects of these drugs. More recently, targeted diseasemodifying and anti-inflammatory therapies, particularly the anti-TNF agents, have emerged, and have proved effective in many patients. While it is encouraging that there is such a wide range of treatment available, the choice brings with it difficult questions concerning the best sequencing of therapy. Moreover, the newer drugs are expensive. The high impact of the disease and the need to make best use of the available treatment make RA a highly suitable subject for a NICE guideline, which it is now my pleasure to introduce.
I have already touched on the exciting therapeutic options for RA, but this guideline addresses many other aspects of management. Because established RA has so many classical features it is easy to forget that at presentation the diagnosis may not be readily apparent, yet early intervention may be important. The guideline offers advice on this problem, including a consideration of the place of newer serological markers of the disease, particularly anti-CCP antibodies. The role of objective measures in the monitoring of disease activity is also considered, as an important component of achieving and maintaining control. The importance of non-pharmacological management of RA is also emphasised, including the many therapeutic interventions which are usually supervised by physiotherapists, occupational therapists and podiatrists; as is the crucial role of the multidisciplinary team including these professionals as well as specialist nurses and doctors.
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