Guidance

Recommendations

Recommendations

People have the right to be involved in discussions and make informed decisions about their care, as described in making decisions about your care.

Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

1.1 Referral, diagnosis and investigations

Referral from primary care

1.1.1

Refer for specialist opinion any adult with suspected persistent synovitis of undetermined cause. Refer urgently (even with a normal acute-phase response, negative anti-cyclic citrullinated peptide [CCP] antibodies or rheumatoid factor) if any of the following apply:

  • the small joints of the hands or feet are affected

  • more than one joint is affected

  • there has been a delay of 3 months or longer between onset of symptoms and seeking medical advice. [2009, amended 2018]

Investigations

If the following investigations are ordered in primary care, they should not delay referral for specialist opinion (see recommendation 1.1.1).

Investigations for diagnosis
1.1.2

Offer to carry out a blood test for rheumatoid factor in adults with suspected rheumatoid arthritis (RA) who are found to have synovitis on clinical examination. [2009]

1.1.3

Consider measuring anti-CCP antibodies in adults with suspected RA if they are negative for rheumatoid factor. [2009, amended 2018]

1.1.4

X-ray the hands and feet in adults with suspected RA and persistent synovitis. [2009, amended 2018]

Investigations following diagnosis
1.1.5

As soon as possible after establishing a diagnosis of RA:

  • measure anti-CCP antibodies, unless already measured to inform diagnosis

  • X-ray the hands and feet to establish whether erosions are present, unless X-rays were performed to inform diagnosis

  • measure functional ability using, for example, the Health Assessment Questionnaire (HAQ), to provide a baseline for assessing the functional response to treatment. [2018]

1.1.6

If anti-CCP antibodies are present or there are erosions on X-ray:

  • advise the person that they have an increased risk of radiological progression but not necessarily an increased risk of poor function, and

  • emphasise the importance of monitoring their condition, and seeking rapid access to specialist care if disease worsens or they have a flare. [2018]

For a short explanation of why the committee made the 2018 recommendations and how they might affect practice, see the rationale and impact section on investigations following diagnosis.

Full details of the evidence and the committee's discussion are in evidence review B: Risk factors.

1.2 Treat-to-target strategy

1.2.1

Treat active RA in adults with the aim of achieving a target of remission or low disease activity if remission cannot be achieved (treat-to-target). Achieving the target may involve trying multiple conventional disease-modifying anti-rheumatic drugs (cDMARDs), and biological or targeted synthetic DMARDs with different mechanisms of action, one after the other. [2018, amended 2024]

1.2.2

Consider making the target remission rather than low disease activity for people with an increased risk of radiological progression (presence of anti-CCP antibodies or erosions on X-ray at baseline assessment). [2018]

1.2.3

In adults with active RA, measure C-reactive protein (CRP) and disease activity (using a composite score such as DAS28) monthly in specialist care until the target of remission or low disease activity is achieved. [2018]

For a short explanation of why the committee made the 2018 recommendations and how they might affect practice, see the rationale and impact section on treat-to-target strategy.

Full details of the evidence and the committee's discussion are in evidence review C: Treat-to-target.

1.3 Communication and education

1.3.1

Explain the risks and benefits of treatment options to adults with RA in ways that can be easily understood. Throughout the course of their disease, offer them the opportunity to talk about and agree all aspects of their care, and respect the decisions they make. [2009]

1.3.2

Offer verbal and written information to adults with RA to:

  • improve their understanding of the condition and its management, and

  • counter any misconceptions they may have. [2009]

1.3.3

Adults with RA who wish to know more about their disease and its management should be offered the opportunity to take part in existing educational activities, including self-management programmes. [2009]

1.4 Initial pharmacological management

Conventional disease-modifying anti-rheumatic drugs

1.4.1

For adults with newly diagnosed active RA:

  • Offer first-line treatment with cDMARD monotherapy using oral methotrexate, leflunomide or sulfasalazine as soon as possible and ideally within 3 months of onset of persistent symptoms.

  • Consider hydroxychloroquine for first-line treatment as an alternative to oral methotrexate, leflunomide or sulfasalazine for mild or palindromic disease.

  • Escalate dose as tolerated. [2018]

1.4.2

Consider short-term bridging treatment with glucocorticoids (oral, intramuscular or intra-articular) when starting a new cDMARD. [2018]

For a short explanation of why the committee made the 2018 recommendations and how they might affect practice, see the rationale and impact section on short-term bridging treatment with glucocorticoids.

Full details of the evidence and the committee's discussion are in evidence review H: Glucocorticoids.

1.4.3

Offer additional cDMARDs (oral methotrexate, leflunomide, sulfasalazine or hydroxychloroquine) in combination in a step-up strategy when the treatment target (remission or low disease activity) has not been achieved despite dose escalation. [2018]

For a short explanation of why the committee made the 2018 recommendations and how they might affect practice, see the rationale and impact section on DMARDs.

Full details of the evidence and the committee's discussion are in evidence review F: DMARDs.

1.5 Further pharmacological management

For guidance on using DMARDs to achieve treatment targets, see section 1.2.1. Also see the MHRA's safety advice on Janus kinase (JAK) inhibitors (April 2023).

See terms used in this guideline for a description and examples of tumour necrosis factor (TNF) inhibitors and JAK inhibitors.

Biological and targeted synthetic DMARDs

1.5.1

If people with RA and their clinicians consider there to be a range of suitable medicines, after discussing the advantages and disadvantages of all the options, the least expensive should be used. Administration costs, dosages, price per dose and commercial arrangements should all be taken into account. [2024]

Moderate RA
1.5.2

For medicines recommended as options in NICE technology appraisal guidance for treating moderate RA (disease activity score [DAS28] of 3.2 to 5.1) that has inadequately responded to intensive therapy with 2 or more conventional DMARDs (cDMARDs) used in combination, see the guidance on:

Severe RA
1.5.3

For medicines recommended as options in NICE technology appraisal guidance for treating severe RA (DAS28 of more than 5.1) that has inadequately responded to intensive therapy with conventional DMARDs (cDMARDs) used in combination, see the guidance on:

1.5.4

Rituximab in combination with methotrexate is recommended as an option in NICE technology appraisal guidance for treating severe RA (DAS28 of more than 5.1) that has inadequately responded to at least 1 TNF inhibitor. For full details, see the guidance on rituximab (TA195, August 2010).

1.5.5

For medicines recommended as options in NICE technology appraisal guidance for treating severe RA (DAS28 of more than 5.1) that has inadequately responded to at least 1 biological DMARD, in people who cannot have rituximab, see the guidance on:

1.5.6

For medicines recommended as options in NICE technology appraisal guidance for treating severe RA (DAS28 of more than 5.1) that has inadequately responded to at least 1 biological DMARD and rituximab, see the guidance on:

Anakinra

1.5.7

On the balance of its clinical benefits and cost effectiveness, anakinra is not recommended for the treatment of RA, except in the context of a controlled, long-term clinical study. [2009]

1.5.8

Do not offer the combination of TNF inhibitor therapy and anakinra for RA. [2009]

Glucocorticoids

1.5.9

Offer short-term treatment with glucocorticoids for managing flares in adults with recent-onset or established disease to rapidly decrease inflammation. [2009]

1.6 Symptom control

1.6.1

Consider oral non-steroidal anti-inflammatory drugs (NSAIDs, including traditional NSAIDs and cox II selective inhibitors), when control of pain or stiffness is inadequate. Take account of potential gastrointestinal, liver and cardio-renal toxicity, and the person's risk factors, including age and pregnancy. [2018]

1.6.2

When treating symptoms of RA with oral NSAIDs:

  • offer the lowest effective dose for the shortest possible time

  • offer a proton pump inhibitor (PPI), and

  • review risk factors for adverse events regularly. [2018]

1.6.3

If a person with RA needs to take low-dose aspirin, healthcare professionals should consider other treatments before adding an NSAID (with a PPI) if pain relief is ineffective or insufficient. [2009, amended 2018]

For a short explanation of why the committee made the 2018 recommendations and how they might affect practice, see the rationale and impact section on symptom control.

Full details of the evidence and the committee's discussion are in evidence review G: Analgesics.

1.7 The multidisciplinary team

1.7.1

Adults with RA should have ongoing access to a multidisciplinary team. This should provide the opportunity for periodic assessments (see 1.9.2 and 1.9.3) of the effect of the disease on their lives (such as pain, fatigue, everyday activities, mobility, ability to work or take part in social or leisure activities, quality of life, mood, impact on sexual relationships) and help to manage the condition. [2009]

1.7.2

Adults with RA should have access to a named member of the multidisciplinary team (for example, the specialist nurse) who is responsible for coordinating their care. [2009]

1.8 Non-pharmacological management

Physiotherapy

1.8.1

Adults with RA should have access to specialist physiotherapy, with periodic review (see 1.9.2 and 1.9.3), to:

  • improve general fitness and encourage regular exercise

  • learn exercises for enhancing joint flexibility, muscle strength and managing other functional impairments

  • learn about the short-term pain relief provided by methods such as transcutaneous electrical nerve stimulators (TENS) and wax baths. [2009]

Occupational therapy

1.8.2

Adults with RA should have access to specialist occupational therapy, with periodic review (see 1.9.2 and 1.9.3), if they have:

  • difficulties with any of their everyday activities, or

  • problems with hand function. [2009]

Hand exercise programmes

1.8.3

Consider a tailored strengthening and stretching hand exercise programme for adults with RA with pain and dysfunction of the hands or wrists if:

  • they are not on a drug regimen for RA, or

  • they have been on a stable drug regimen for RA for at least 3 months. [2015]

1.8.4

The tailored hand exercise programme for adults with RA should be delivered by a practitioner with training and skills in this area. [2015]

Podiatry

1.8.5

All adults with RA and foot problems should have access to a podiatrist for assessment and periodic review of their foot health needs (see 1.9.2 and 1.9.3). [2009]

1.8.6

Functional insoles and therapeutic footwear should be available for all adults with RA if indicated. [2009]

Psychological interventions

1.8.7

Offer psychological interventions (for example, relaxation, stress management and cognitive coping skills [such as managing negative thinking]) to help adults with RA adjust to living with their condition. [2009]

NICE has published a guideline on depression in adults with a chronic physical health problem.

Diet and complementary therapies

1.8.8

Inform adults with RA who wish to experiment with their diet that there is no strong evidence that their arthritis will benefit. However, they could be encouraged to follow the principles of a Mediterranean diet (more bread, fruit, vegetables and fish; less meat; and replace butter and cheese with products based on vegetable and plant oils). [2009]

1.8.9

Inform adults with RA who wish to try complementary therapies that although some may provide short-term symptomatic benefit, there is little or no evidence for their long-term efficacy. [2009]

1.8.10

If an adult with RA decides to try complementary therapies, advise them:

  • these approaches should not replace conventional treatment

  • this should not prejudice the attitudes of members of the multidisciplinary team, or affect the care offered. [2009]

1.9 Monitoring

1.9.1

Ensure that all adults with RA have:

  • rapid access to specialist care for flares

  • information about when and how to access specialist care, and

  • ongoing drug monitoring. [2018]

1.9.2

Consider a review appointment to take place 6 months after achieving treatment target (remission or low disease activity) to ensure that the target has been maintained. [2018]

1.9.3

For adults with RA who are receiving a biological or targeted synthetic DMARD, continue treatment only if there is a moderate response (as defined in the relevant NICE technology appraisal guidance listed in section 1.5) at 6 months. Stop treatment if this is not maintained. [2024]

1.9.4

Offer all adults with RA, including those who have achieved the treatment target, an annual review to:

  • assess disease activity and damage, and measure functional ability (using, for example, the Health Assessment Questionnaire [HAQ])

  • check for the development of comorbidities, such as hypertension, ischaemic heart disease, osteoporosis and depression

  • assess symptoms that suggest complications, such as vasculitis and disease of the cervical spine, lung or eyes

  • organise appropriate cross referral within the multidisciplinary team

  • assess the need for referral for surgery (see section 1.10)

  • assess the effect the disease is having on a person's life.

    Follow recommendation 1.2.1 if the target is not maintained. [2009, amended 2020]

1.9.6

Do not use ultrasound for routine monitoring of disease activity in adults with RA. [2018]

For a short explanation of why the committee made the 2018 recommendations and how they might affect practice, see the rationale and impact section on monitoring.

Full details of the evidence and the committee's discussion are in evidence review E: Frequency of monitoring.

1.10 Timing and referral for surgery

1.10.1

Offer to refer adults with RA for an early specialist surgical opinion if any of the following do not respond to optimal non-surgical management:

  • persistent pain due to joint damage or other identifiable soft tissue cause

  • worsening joint function

  • progressive deformity

  • persistent localised synovitis. [2009]

1.10.2

Offer to refer adults with any of the following complications for a specialist surgical opinion before damage or deformity becomes irreversible:

  • imminent or actual tendon rupture

  • nerve compression (for example, carpal tunnel syndrome)

  • stress fracture. [2009]

1.10.3

When surgery is offered to adults with RA, explain that the main expected benefits are:

  • pain relief

  • improvement, or prevention of further deterioration, of joint function, and

  • prevention of deformity.

    Cosmetic improvements should not be the dominant concern. [2009]

1.10.4

Offer urgent combined medical and surgical management to adults with RA who have suspected or proven septic arthritis (especially in a prosthetic joint). [2009]

1.10.5

If an adult with RA develops any symptoms or signs that suggest cervical myelopathy (for example, paraesthesia, weakness, unsteadiness, reduced power, extensor plantars):

  • request an urgent MRI scan, and

  • refer for a specialist surgical opinion. [2009]

1.10.6

Do not let concerns about the long-term durability of prosthetic joints influence decisions to offer joint replacements to younger adults with RA. [2009]

Terms used in this guideline

Bridging treatment

Glucocorticoids used for a short period of time when a person is starting a new DMARD, intended to improve symptoms while waiting for the new DMARD to take effect (which can take 2 to 3 months).

Conventional disease-modifying anti-rheumatic drugs (cDMARDs)

Conventional disease-modifying anti-rheumatic drugs are synthetic drugs that modify disease rather than just alleviating symptoms. They include methotrexate, sulfasalazine, leflunomide and hydroxychloroquine, but do not include biological DMARDs and targeted synthetic DMARDs.

Janus kinase (JAK) inhibitor

A targeted synthetic DMARD that inhibits the inflammatory activity of the Janus kinase enzymes. They are given orally. Examples include baricitinib, filgotinib, tofacitinib and upadacitinib.

Palindromic

Palindromic rheumatism is an inflammatory arthritis that causes attacks of joint pain and swelling similar to RA. Between attacks the joints return to normal.

Step-up strategy

Additional DMARDs are added to DMARD monotherapy when disease is not adequately controlled.

Step-down strategy

During treatment with 2 or more DMARDs, tapering and stopping at least 1 drug once disease is adequately controlled.

Synovitis

Soft tissue joint swelling.

Treat-to-target

A treat-to-target strategy is a strategy that defines a treatment target (such as remission or low disease activity) and applies tight control (for example, monthly visits and respective treatment adjustment) to reach this target. The treatment strategy often follows a protocol for treatment adaptations depending on the disease activity level and degree of response to treatment.

Tumour necrosis factor (TNF) inhibitor

A biological DMARD that inhibits an inflammatory protein, tumour necrosis factor-alpha. They are given by injection or infusion. Examples include adalimumab, certolizumab pegol, etanercept, golimumab, and infliximab.