These recommendations are based on the National Institute for Health and Clinical Excellence (NICE) guideline Rheumatoid arthritis: national clinical guideline for management and treatment in adults [National Collaborating Centre for Chronic Conditions, 2009; NICE, 2009], and the British Society for Rheumatology and British Health Professionals in Rheumatology guidelines for the management of rheumatoid arthritis [Luqmani et al, 2006; Luqmani et al, 2009].

Multidisciplinary team work

• NICE reviewed good quality evidence (five randomized controlled trial [RCTs] and three case series) on the effectiveness of multidisciplinary team work in RA and concluded that there is a lack of evidence to show whether or not there is any benefit in the long term. NICE recognized that a multidisciplinary approach addresses issues beyond the purely medical problems, and complements the skills of the rheumatologist.

Physiotherapy

• NICE reviewed good quality evidence (five systematic reviews/meta-analyses and 17 RCTs) for the effectiveness of physiotherapy in RA and concluded that exercise (aerobic, joint flexibility, muscle strength) improves fitness, enhances psychological status, reduces pain and fatigue, and has a positive effect on functional capacity, without exacerbating RA or accelerating joint damage.

Occupational therapy

• NICE reviewed the evidence (two meta-analyses and five RCTs) on psychological interventions, or splints and orthoses, in RA and concluded:
• There was limited evidence of benefit for hand splints, although NICE recognized that many people find them beneficial.
• There was good evidence that psychological interventions (for example, relaxation, stress management, and cognitive coping skills) have a beneficial impact on pain and functional ability, and that stress reduction techniques and cognitive behavioural therapy could improve some aspects of psychological status.

Complications and comorbidities

• The inflammatory processes of RA can directly or indirectly affect most organs in the body, and result in premature death.
• Cardiovascular disease accounts for about half of all deaths in RA [van Doornum et al, 2002]. The risks of cardiovascular morbidity and mortality are approximately double those of the rest of the population.

Self-care advice and education

• NICE reviewed the evidence from observational and qualitative studies and concluded that people with RA felt that many issues (such as pain and fatigue, depression, sexual relationships, mobility, and inability to work or undertake activities) were not satisfactorily addressed, and they wanted more involvement in the management of their disease.
• A Cochrane systematic review and meta-analysis (31 RCTs) suggested that education had small, short-term effects on disability, psychological status, and depression. There was no evidence of long-term benefits or cost-effectiveness. However, due to the clear desire for education, NICE stated that a range of activities should be made available to people with RA until further research highlights the most appropriate educational methods.

Diet

• NICE reviewed the evidence (three meta-analyses and 14 RCTs) on diet and dietary supplements in RA and concluded there was no consistent evidence of benefit (in terms of symptoms, joint damage, or function and quality of life) of any one particular diet.
• NICE concluded that the principles of a Mediterranean diet should be highlighted if the person wishes to modify their diet, as people with RA are at an increased risk of cardiovascular disease compared with the general population.

Specialist advice

• Specialist advice or referral is recommended for a flare of rheumatoid arthritis:
• For an intra-articular corticosteroid injection (in the absence of the expertise to do this in primary care).
• To organize an early follow-up appointment to titrate the person's disease-modifying anti-rheumatic drugs (DMARDs). See the CKS topic on DMARDs.

Corticosteroids

• The National Institute for Health and Clinical Excellence (NICE) recommends that corticosteroids should be used to treat a flare of RA, but gives no preference on the type of corticosteroid, or on the route of administration [NICE, 2009].
• An intramuscular corticosteroid will allow control of dosage, and is preferred to an oral corticosteroid [SIGN, 2004]. The choice of intra-articular corticosteroid is based on feedback from CKS expert reviewers. Triamcinolone is not recommended for small joints because of the risk of extra-articular extravasation and soft tissue atrophy. Lidocaine is not recommended for injection into small joints with hydrocortisone because there is not enough room in the intra-articular space for both.
• The use of corticosteroids to treat flares of RA is not based on trial evidence. NICE recognizes that this practice is common and is seen to be beneficial, and therefore recommends the use of corticosteroids for the treatment of flares [National Collaborating Centre for Chronic Conditions, 2009]. The dose of oral corticosteroids for a flare is based on feedback from CKS expert reviewers.
• The long-term adverse effects of corticosteroid use are a cause for concern, and there is conflicting evidence on the disease-modifying effects of corticosteroids taken in the long term (for example 2 years) [Kirwan, 1995; Capell et al, 2004; NICE, 2009].

This recommendation is based on the National Institute for Health and Clinical Excellence (NICE) guideline Rheumatoid arthritis: national clinical guideline for management and treatment in adults [National Collaborating Centre for Chronic Conditions, 2009; NICE, 2009].

Disease-modifying anti-rheumatic drugs (DMARDs)

• After reviewing the evidence (one meta-analysis, six randomized controlled trials, and three cohort studies), NICE concluded that for symptoms, quality of life, ability to achieve remission, and slowing of joint damage, combination therapies appear to be superior to monotherapy. There is no difference in tolerability between monotherapy and combination therapies.
• NICE stated that a combination DMARD regimen, compared with monotherapy, is more cost-effective in the management of rheumatoid arthritis.

Corticosteroids

• After reviewing the evidence, NICE concluded that the most successful and cost-effective combination therapy regimens all used corticosteroids in one form or another. Therefore, the use of corticosteroids is recommended when starting combination DMARD treatment.

This recommendation is based on the National Institute for Health and Clinical Excellence (NICE) guideline Rheumatoid arthritis: national clinical guideline for management and treatment in adults [National Collaborating Centre for Chronic Conditions, 2009; NICE, 2009].

• After reviewing the evidence (one meta-analysis, two RCTs, and one case series) on complementary and alternative therapies (such as acupuncture, massage therapy) in RA, NICE concluded that there was a lack of evidence of benefit.
• At best, complementary therapy gave short-term benefits similar to analgesics.

These recommendations are based on the National Institute for Health and Clinical Excellence (NICE) guideline Rheumatoid arthritis: the management of rheumatoid arthritis [NICE, 2009].

• After reviewing four cross-sectional studies and one retrospective case series, NICE concluded that there was a lack of evidence to address the question of appropriate timing for surgery. However, NICE considered it appropriate to involve surgeons early, even if surgery was not urgently indicated, particularly where the outcome could be jeopardized by a delay in referral (for example, possible tendon rupture, localized non-responding synovitis).
• Indications for joint replacement in RA should be considered in the same way as for people with osteoarthritis. However, NICE stated that people with RA might be considerably younger and the wear and tear of the prosthetic joint could well be less (in view of the polyarthritic nature of RA). Therefore, people should be considered for a joint replacement regardless of their age.