GPAC: Guidelines and Protocols Advisory Committee

Rheumatoid Arthritis: Diagnosis and Management

Effective Date: May 1, 2006

Summary | Flow Sheet | Patient Guide | Full Guideline in PDF

Recommendations and Topics

Scope and Introduction

1. Differentiate inflammatory from non-inflammatory arthritis

2. Differentiate RA from other inflammatory arthritides

3. Testing

4. Management of Early RA (ERA)

5. Management of Established RA

6. Consider implications of chronic disease

Summary

References and Resources

Appendix: Disease Modifying Arthritis Drugs (DMARDs) table

Scope:

The guideline summarizes current recommendations for diagnosis and treatment of Rheumatoid Arthritis (RA) for patients 16 years of age and older.

Introduction

Rheumatoid Arthritis (RA) is not a benign disease. RA is associated with decreased life expectancy. The risk of cardiovascular mortality is twice that of the general population. Affecting approximately 1% of the adult population, RA is associated with considerable disability. RA adversely impacts an individual’s quality of life and results in increased financial burden both to the individual and society through medical costs and loss of productivity.

It is now well recognised that there is a "window of opportunity" early in the disease process to initiate treatment which will fundamentally change the course of the disease. Treatment must be started early to maximise the benefits of medications and prevent joint damage. The use of traditional medications in combination and the new biologic therapies has revolutionised the paradigm of RA treatment in recent years.¹

In this new era of RA treatment, specialist care has become increasingly important in managing complex regimens. Access to timely specialized care is not universally available. This guideline is intended to aid in initiating early recognition and intervention and managing patients with this chronic disease.

The approach to care of patients with RA should be considered as falling into two groups.

• Early RA (ERA) is defined as patients with symptoms of less than 3 months duration.
• Patients with established disease who have symptoms due to inflammation and/or joint damage.

The treatment approach varies depending on whether the symptoms arise from inflammation or joint damage making the differentiation vital.

Recommendations to Improve Quality of Care

RECOMMENDATION 1: Differentiate inflammatory from non-inflammatory arthritis

RECOMMENDATION 2: Differentiate RA from other inflammatory arthritides

• RA likely if:
• Morning stiffness > 30 minutes
• Painful swelling of 3 or more joints
• Involvement of hands and feet (especially MCP and MTP joints)
• Duration of 4 or more weeks
• Differential diagnoses include: crystal arthropathy, psoriatic arthritis, lupus, reactive arthritis, spondyloarthropathies.

N.B. Always consider infection

• Features suggesting alternative diagnosis include
• Mucosal ulcers, photosensitivity, psoriasis, skin rashes
• Raynaud’s
• Ocular inflammation
• Urethritis
• Inflammatory bowel disease
• Infectious diarrhea
• Nephritis
• Isolated distal interphalangeal (DIP) joints
• It should be noted that extra-articular manifestations are an indication of more severe disease and thus have prognostic value. Established RA may have extra-articular manifestations including:

RECOMMENDATION 3: Testing

RA is a clinical diagnosis. There are no tests that are completely reliable in making the diagnosis. Tests are primarily used to monitor the disease or exclude other types of arthritis.

RECOMMENDATION 4: Management of Early RA (ERA)

• Patient education: give attached RA guide for adult patients.
• Referral to PT and OT with expertise in RA and indicate "Urgent: new-onset RA"
• Prior to starting medications do baseline CBC, creatinine, electrolytes, and blood pressure.
• Start NSAIDS for pain management.
• Specialist intervention has been shown to improve RA outcomes. Specialist referral should indicate "Urgent: new-onset RA".
• Start hydroxychloroquine. (See Appendix for DMARD information.)
• Start sulfasalazine and methotrexate if confident about diagnosis and management and the patient is not pregnant. Combination DMARD therapy is the current standard of care.
• If symptoms severe while waiting for specialist assessment add low-dose prednisone (up to 10 mg/day).

RECOMMENDATION 5: Management of Established RA

Continuing joint inflammation will lead to joint damage. Most patients will require long-term DMARD therapy. The objective of treatment is to suppress all inflammation and prevent joint damage.

Follow-up by GP every 3-6 months and specialist every 6-12 months after disease is controlled.

At each visit:

• List and assess current drug therapy including dose and monitoring for side effects (see DMARD table in Appendix)
• Assess patient for active joint inflammation and disease activity
• Review Recommendation 1
• Consider investigations: ESR or CRP
• Focus exam to most troublesome joints
• Differentiate inflammation versus damage
• Scan for general health concerns, co-morbidities, and extra-articular manifestations

If the assessment suggests ongoing active inflammation then:

• Review adherence to medication regimen, consider adjusting dosages or substituting/adding alternative medications, consider referral to specialist, and consider referral to Physiotherapist (PT) and/or Occupational Therapist (OT) with expertise in RA.

If the assessment suggests joint damage then:

• Consider referral to PT and/or OT
• Consider referral to Orthopaedic Surgeon
• Pain relieving modalities

Always consider that patients may have a combination of inflammation and damage.

For surgical procedures consider neck instability, increased risk of infection, and implications of medications especially steroids

RECOMMENDATION 6: Consider implications of chronic disease

As with all chronic diseases, optimal outcome is achieved through a multi-disciplinary approach coordinated by the Family Doctor. Consider or review:

• Pain management
• Psychosocial issues
• Immunization (annual flu vaccine, pneumococcal vaccination)
• Osteoporosis assessment and preventive measures
• RA is a risk factor for coronary artery disease. Consider dyslipidemia and minimize other risk factors.
• Encourage Self-Management

Summary

Rheumatoid arthritis (RA) is not a benign disease and affects about 1% of the BC adult population. Early recognition and intervention clearly improves outcome. DMARDs, particularly when used early, change the disease process and have been proven to reduce damage and disability. Treatment is multi-disciplinary involving regular follow-up, medications, physiotherapy, self-management and other support.

References and Resources:

1. Guidelines for the Management of Rheumatoid Arthritis American College of Rheumatology Subcommittee on Rheumatoid Arthritis Guidelines. Arthritis & Rheumatism 2002;46(2):328-346.
2. Getting a grip on arthritis best practice guidelines The Arthritis Society. (2004).
3. RA information and clinical resources available at www.rheuminfo.com
4. British Society of Rheumatology Guideline on Standards of Care for persons with Rheumatoid Arthritis. Kennedy T (Chair of the Guideline Working Group). BSR Rheumatology 2005 44(3):269-270. Available here.
5. Canadian consensus statement on early optimal therapy in early Rheumatoid Arthritis. Bykerk BP, Baron M, Boire M, et.al. Available here (PDF).
6. Rheumatoid Arthritis. Treatments. Matsumoto AK, Bathon J. Available at http://www.hopkins- arthritis.org/rheumatoid/rheum_treat.html.
7. Search for a Physiotherapist by name or workplace Physiotherapy Association of British Columbia 604 736-5130. www.bcphysio.org or www.bcphysio.org/app/index.cfm?fuseaction=public.home
8. The Arthritis Society Toll free phone number: 1 800 321-1433

Sponsors

This guideline was developed by the Guidelines and Protocols Advisory Committee, approved by the British Columbia Medical Association and adopted by the Medical Services Commission. Partial funding for this guideline was provided by the Health Canada Primary Health Care Transition Fund.

Revised Date: April 1, 2007

This guideline is based on scientific evidence current as of the effective date.

Appendix: Disease Modifying Arthritis Drugs (DMARDs) table

Disclaimer

The Clinical Practice Guidelines (the "Guidelines") have been developed by the Guidelines and Protocols Advisory Committee on behalf of the Medical Services Commission. The Guidelines are intended to give an understanding of a clinical problem, and outline one or more preferred approaches to the investigation and management of the problem. The Guidelines are not intended as a substitute for the advice or professional judgment of a health care professional, nor are they intended to be the only approach to the management of clinical problems.

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