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Rheumatoid arthritis - Management
Basis for recommendation

This approach to suspecting rheumatoid arthritis (RA) 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].

  • NICE recommends that the most important clinical feature to detect a new presentation of RA is synovitis, and if the small joints of the hands and feet are involved, the primary healthcare professional should lower their threshold for suspecting RA.
  • NICE recommends that a diagnosis of RA should be suspected in anyone with persistent synovitis. However, NICE does not provide guidance on how long the person should have synovitis before it is considered to be 'persistent'. Therefore, CKS recommends that clinical judgement be used to decide whether synovitis is persistent or not.
  • NICE states that diagnosis of RA should be based on clinical findings. After reviewing good quality evidence (one cohort study and 12 case series), NICE concluded that the following clinical features help identify people who are likely to have persistent synovitis and go on to develop RA:
    • A history of ever having experienced prolonged morning stiffness (and this is more helpful than currently having morning stiffness).
    • Both swelling and tenderness in affected joints, particularly small joints.
    • Involvement of proximal interphalangeal joints and metacarpophalangeal joints.
    • Symmetrical joints are affected.
    • A greater number of joints are affected.
    • An inability to make a fist or flex fingers.
    • A positive metacarpophalangeal squeeze test.
  • The American College of Rheumatology (ACR) classification criteria for RA have been widely used for diagnosis [American College of Rheumatology, 1987]. However, NICE states that a diagnosis of RA should no longer be constrained by the ACR criteria.
    • The ACR criteria are mainly used for research purposes. There is good quality evidence (one cohort study and 12 case series) to suggest the ACR criteria are not useful for discriminating between RA and other conditions presenting with synovitis.

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