All forms of inflammatory arthritis have similar management strategies coordinated through a multidisciplinary team.
Pharmacological treatments are prescribed to relieve painful symptoms and to slow or stop disease progression, thereby limiting future impairment.
We recommend that treatment teams should provide ongoing support by promoting self-management though education, coordinating regular reviews, and ensuring access to urgent advice.
Pharmacological management
Since 2001, we have published over 30 technology appraisals of medicines for treating inflammatory arthritis, meaning people with inflammatory arthritis now have more treatment options. Recent changes in the cost of some medicines to the NHS mean that many more people with inflammatory arthritis now have access to innovative biological medicines.
Starting treatment
Our guideline on RA recommends treating active RA in adults with the aim of achieving a defined target of remission, or low disease activity if remission cannot be achieved. This approach is called ‘treat-to-target’. Data from the British Society of Rheumatology’s National Early Inflammatory Arthritis (NEIA) Audit show that most people with RA have a personal treatment target set and agreed.
The proportion of people with rheumatoid arthritis who have had a treatment target agreed has increased
Source: British Society for Rheumatology, NEIA Audit, 2020
Our quality standard on SpA states that people with suspected SpA should be referred to a rheumatologist to reduce delays in diagnosis and starting treatment.
Our quality standard on RA states that adults with active RA should start treatment within 6 weeks of referral, with monthly monitoring until their treatment target is met. This is important because delaying therapy is linked to worse functional impairment, irreversible damage to joints and a lower chance of achieving sustained disease remission.
The proportion of people with early inflammatory arthritis who were started on a disease-modifying antirheumatic drug (DMARD) within 6 weeks of referral has increased
Source: British Society for Rheumatology, NEIA Audit, 2020
Disease-modifying antirheumatic drugs
For most people with RA and peripheral SpA, we recommend initial treatment with a conventional disease-modifying antirheumatic drug (DMARD), such as methotrexate. For axial SpA we recommend offering a non-steroidal anti-inflammatory drug (NSAID), such as ibruprofen, followed by a DMARD for people whose disease has responded inadequately. Unlike NSAIDs, DMARDs treat the disease, rather than minimising symptoms.
In recent years, many more innovative medicines have become available for people whose arthritis has not responded well enough to first-line treatments. These synthetic and biological DMARDs are more targeted and many work more quickly than conventional treatments.
To achieve their treatment target, a person may have to try multiple conventional and biological DMARDs with different mechanisms of action. In 2020, we updated the treat-to-target section of our RA guideline to clarify that people can have multiple treatments one after the other to achieve their treatment targets.
Many of the most commonly prescribed biological DMARDs, such as adalimumab and etanercept, belong to a class of medicines called anti-tumour necrosis factor (TNF) inhibitors. Anti-TNF inhibitors have been approved as a treatment for RA, axial SpA and peripheral SpA.
More recently, we have recommended medicines such as baricitinib and tofacitinib to treat RA and some types of peripheral SpA. These belong to a class called Janus kinase (JAK) inhibitors, and target a different part of the immune pathway. This means that people who either cannot tolerate conventional DMARDs and anti-TNF inhibitors, or whose treatment targets have not been met while having them, might still benefit from JAK inhibitors.
Another consideration is that JAK inhibitors are given in tablet form, unlike most other treatments, which are given by injection or infusion. This may make them more convenient for people to take at home. During the coronavirus pandemic, we published a COVID-19 rapid guideline on rheumatological autoimmune, inflammatory and metabolic bone disorders. It recommends that healthcare professionals should think about whether changes in people’s medicines might be needed during the pandemic, including dosage, route of administration and mode of action.
Since first becoming available, prescribing of JAK inhibitors recommended by NICE has steadily increased. Some of these medicines are also recommended for treating other inflammatory conditions. For example, baricitinib is recommended for treating atopic dermatitis and tofacitinib for ulcerative colitis.
Prescribing of Janus kinase (JAK) inhibitors has increased since baricitinib and tofacitinib were recommended in 2017
Source: NHS Digital, NICE technology appraisals in the NHS in England
Transitioning to biosimilars
Over the last 20 years, biological medicines have transformed the treatment of inflammatory arthritis, but are much more expensive than conventional treatments. Since 2002, we have recommended several biological treatments for arthritis, helping to ensure fair and equitable access to these high-cost medicines.
Biological medicines are currently the largest cost and cost growth area across the NHS medicines budget. In particular, the cost of biological medicines prescribed to treat inflammatory arthritis is among the highest pharmaceutical cost within many trusts. Biosimilars are biological medicines that are very similar and clinically equivalent to an existing medicine, but much cheaper.
Biosimilars can only be made once the patent has expired on the original licensed medicine. Since 2015, we have, when possible, considered biosimilars alongside the original biological medicine when approving new treatments. Using a new commissioning framework, NHS England is transitioning towards the use of biosimilar medicines
£83 million reduction in rheumatology drug spending between 2017 and 2019, largely driven by the switch to biosimilars. Source: Getting it Right First Time (GIRFT), Rheumatology report, 2021
The increasing availability of biosimilar versions of biological medicines has led to estimated cost savings of close to £300 million per year for the NHS. Adalimumab, which is used to treat multiple inflammatory conditions, including arthritis, was the most expensive single medicine for hospitals at a cost of more than £400 million per year. This was recently switched to a biosimilar, leading to savings of over £100 million per year. (NHS England, News, 2019)
As a direct result of these cost savings, we are now able to recommend several biological treatments to around 25,000 people with moderate RA that has not responded to conventional therapies. These treatments were previously only recommended for severe RA.
Organisation of care
We recommend that adults with RA or SpA should have ongoing access to a range of services and specialists in multidisciplinary teams. This should provide opportunity for periodic assessments of the effect of the disease on their lives (such as pain, fatigue, mobility, ability to work, impact on relationships and quality of life) and help them to manage their condition.
These multidisciplinary teams should include:
- specialist physiotherapy
- podiatry services
- occupational therapy
- psychological services.
My experience of over 20 years under the care of the same rheumatology consultant gave me confidence in both the medical support and therapy that I received. I believe this continuity and knowledge of my particular circumstances enabled me to stay in employment and secure a successful career, that I may not have otherwise found without this support.
Of the 118 trusts that provided information to the British Society for Rheumatology National Early Inflammatory Arthritis (NEIA) Audit, 93% provided access to physiotherapy, 76% to podiatry services, 95% to occupational therapy services, and 38% to psychological services. Specialist clinics were also available in many departments, with 77% providing early arthritis clinics, and 44% of trusts providing a dedicated axial SpA clinic. (APPG for Axial SpA Report, 2020)
As part of their ongoing care, adults with RA should have a comprehensive annual review. Our quality standard on RA states that this should be coordinated by rheumatology services. Data from NHS Digital’s Quality and Outcomes Framework (2020 data) indicates that 81% of people with RA on a GP register had a face-to-face review in the previous 12 months.
However, the NEIA audit shows that only 48% of people with a diagnosis of RA were reported to have had an annual review 12 months after diagnosis. The proportion of people having this first annual review also showed large regional variation, ranging from 15% in London to 65% in the Northeast.
Education and support
It is important that adults with inflammatory arthritis have a good understanding of their condition and its management. This will empower them to be more involved in shared decision making, to better manage pain, disease flares and fatigue, and to improve their quality of life.
To encourage this, we recommend that adults with RA should be given opportunities throughout the course of their disease to take part in educational activities that support self-management. Information provided by rheumatology departments for the NEIA audit indicates that 96% of people diagnosed with early inflammatory arthritis were offered access to education and information on self-management.
We also recommend that adults with SpA should be given information about their condition, which healthcare professionals will be involved with their care, and how and when to get in touch with them.
Information and support is provided in a number of ways following a diagnosis of axial SpA
Source: APPG for Axial SpA Report, 2020
Shared decision making is of particular importance when deciding on the appropriate medicine to manage someone’s condition. Most people will be unfamiliar with the benefits and risks of biological medications and will need guidance before making an informed choice. Information on shared decision making is included in our shared decision making guideline.
We recommend that the choice of treatment for axial SpA should be made after discussion between a person and their clinician about the advantages and disadvantages of the available treatments. All trusts have reported that they offer some form of guidance before offering biological treatment, with the majority (56%) providing information through clinic appointments. (APPG for Axial SpA Report, 2020)
While it is encouraging to note such high levels of information and support provision being reported by trusts, there are still areas for improvement. An unpublished survey done by arthritis advocate groups in 2019 showed that only 41% of people said that their consent was sought when switching treatments from an originator medicine to a biosimilar version. This may suggest differing perspectives from clinicians and patients on the level of support and information provided. (APPG for Axial SpA Report, 2020)
Living with a long-term condition: mental health and wellbeing
People with long-term physical conditions such as arthritis have a higher rate of mental health conditions. In England, 14% of all people report feeling anxious or depressed, which rises to 24% in people with a long-term musculoskeletal condition (Public Heath England, Musculoskeletal Conditions).
We have published a guideline on the recognition and management of depression in adults with a chronic physical health problem. We have also published a guideline on primary and secondary chronic pain, which recognises that the experience of pain is always influenced by social, emotional and biological factors.
The NHS Long Term Plan aims to continue the expansion of Improving Access to Psychological Therapies (IAPT) services for adults and older adults with common mental health disorders, with a focus on those with long-term health conditions. To help meet this goal, we worked with NHS England to produce advice on digitally enabled therapies for use in IAPT services, with the aim of expanding the provision of psychological therapies and improving access to digital services.
Managing disease flares
I've realised as a long-term patient I need to ask my questions as well as listen carefully to options presented. This helps me to make an informed choice of treatment to support my body at a time of flare which in turn helps strengthen my mental health ready to live through the more difficult times. I find now I recover more quickly from a flare-up each time I experience one.
It is important that adults with inflammatory arthritis who experience disease flares can quickly access rheumatology services for advice. We recommend that adults with RA having disease flares or treatment-related side effects should receive advice within a day of contacting rheumatology services.
Encouragingly, over 92% of people with a diagnosis of RA were provided with access to rheumatology specialist advice. However, emergency advice (within 24 hours) was only available in 50% of trusts. (British Society for Rheumatology, NEIA Audit, 2020.
We recommend that SpA flares are managed in either specialist care or primary care depending on the person’s needs, indicating the need for a personalised care plan. Data from the APPG report shows that only 12% of providers offered a written care plan to support people with a flare. Several providers offered alternative arrangement, including verbal information or leaflets (51%), a helpline (40%), general care plans (4%) or a specialist flare clinic (4%). However, many providers (25%) did not provide a written plan, with no alternative arrangements in place. This represents an area for significant improvement.
Insight from Zoë Chivers
Managing inflammatory arthritis requires ongoing support from a multidisciplinary care team that includes specialist nurses, physiotherapists, podiatrists, occupational therapy and mental health support, as well as access to health and wellbeing services relating to smoking cessation, physical activity and nutrition.
Workload pressures mean that services are currently struggling to deliver all the specialist support needed, especially those focused on education and non-pharmacological treatments, which makes good long-term self-management more difficult for patients.
These pressures also mean that specialists are often unable to provide advice within 1 working-day of contacting rheumatology services for disease flares or possible treatment-related side effects, in line with NICE quality standards.