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].

Referral

• People with persistent synovitis should be referred as soon as possible for diagnosis and treatment as the suppression of inflammation in the early stages of rheumatoid arthritis (RA) can result in substantial improvements in outcomes. There is a narrow window of opportunity for disease-modifying anti-rheumatic drugs (DMARDs) to influence long-term outcomes.
• After reviewing good quality evidence (one meta-analysis, six randomized controlled trials [RCTs], and three cohort studies) on DMARDs in RA, NICE concluded that a prompt introduction of DMARDs can lead to benefits (in terms of symptoms, joint damage, function, and quality of life; demonstrated through up to 5 years of follow up) compared with a delayed start. Early treatment also resulted in fewer adverse effects.
• After reviewing good quality evidence (one cohort study and 12 case series), NICE concluded that an urgent referral is necessary for persistent synovitis affecting the small joints, or more than one joint, or when symptoms have lasted more than 3 months, as these clinical features are associated with a poor prognosis, and are likely to lead to persistent synovitis needing treatment.
• In early RA, blood tests may be normal despite significant disabling disease. Therefore, it is important that normal test results should not delay a referral.

Paracetamol with, or without, codeine

• There are few good quality trials of analgesics in RA, and none comparing paracetamol alone with placebo. However, there is good evidence from a randomized controlled trial on the efficacy of paracetamol in osteoarthritis [National Collaborating Centre for Chronic Conditions, 2008].
• NICE considered that there was enough evidence to suggest that paracetamol and codeine are effective in controlling pain in RA. In addition, NICE stated that the use of paracetamol and/or codeine will decrease the person's reliance on nonsteroidal anti-inflammatory drugs (NSAIDs) and coxibs, and therefore reduce the risk of adverse effects.
• CKS recommends that paracetamol and codeine are prescribed separately for suspected RA, so they can be individually titrated; combination products (such as co-codamol) are not recommended unless the individual has stable pain requirements that necessitate full dosage of both paracetamol and codeine at each administration.

NSAIDs and coxibs

• After reviewing good quality evidence (eleven RCTs and one extension of an RCT), NICE concluded that NSAIDs and coxibs are useful in reducing the symptoms of RA (such as pain, swelling, and morning stiffness). However, these findings were based on short-term studies (average of 12 weeks), in people with established RA. There are very few long-term studies, and no studies were identified in people with recent-onset RA.
• NICE stated that NSAIDs should be used after a trial of paracetamol and/or codeine, and on an as required basis. This approach is to minimize adverse effects, and reduce the possibility of masking the symptoms and signs of RA prior to a specialist referral. These recommendations are based on expert opinion rather than trial evidence.

Corticosteroids

• After reviewing the evidence (six RCTs), NICE recommended that corticosteroids are used in recent-onset RA as part of a combination regimen with DMARDs. However:
• As corticosteroids are recommended only once a diagnosis has been made, CKS does not recommend initiating them in primary care for suspected RA.
• The use of corticosteroids in primary care may mask the symptoms and signs of RA, making diagnosis more difficult for the specialist.