1 Introduction

1.1 Background

Rheumatoid arthritis (RA) affects approximately 1% of the population and is more common in women than in men. The course of RA is variable and unpredictable but for a significant number of patients it is a severe disease resulting in persistent pain and stiffness, progressive joint destruction, functional decline and premature mortality.^{1, 2, 3} Equally important to affected individuals is the potential loss of social and financial independence.⁴

The disease also exerts a considerable burden on society in terms of direct (e.g. medical care) and indirect costs (e.g. effects on the individual's ability to work, see section 3.6).^{5, 6}

1.2 The need for a guideline

The traditional management of RA, the 'treatment pyramid', begins with mild, mainly symptomatic measures and defers the use of disease modifying drugs until the disease has progressed further. However, increasing recognition that, for many patients, RA is not a benign condition with a good prognosis has prompted a re-evaluation of therapeutic strategies and the clinical effectiveness of the traditional approach has been widely challenged.^{7, 8, 9} It has been shown that erosive change, leading to joint destruction, often occurs in early disease ^{10, 11, 12, 13, 14} and that early loss of function may be irreversible. In addition, evidence is now accumulating that early more aggressive intervention can improve longer term disease outcome.¹⁵ There is therefore a need for an evidence-based guideline for the management of early RA.

1.3 Remit

This guideline addresses diagnosis of early RA, its pharmacological treatment, and the role of the multidisciplinary team in improving care of the RA patient. It is hoped that the guideline will inform standards for practice for rheumatologists, general practitioners (GPs), rheumatology nurse specialists, physiotherapists, occupational therapists, dietitians, podiatrists and pharmacists.

At present there is no formal definition of 'early RA'. It is defined in this guideline as disease duration of <5 years from onset of symptoms.

The guideline does not cover:

• Treatment of co-morbidity (e.g. anaemia, osteoporosis)
• Complications of drug therapy and their management
• Treatment of extra-articular disease (e.g. vasculitis, ocular complications, amyloid)
• Surgical intervention
• Management of children with arthritis.

References

1 Wolfe F, Zwillich SH. The long-term outcomes of rheumatoid arthritis: a 23-year prospective, longitudinal study of total joint replacement and its predictors in 1,600 patients with rheumatoid arthritis. Arthritis Rheum 1998; 41: 1072-82.

2 Pincus T. Rheumatoid arthritis: a medical emergency? Scand J Rheumatol Suppl 1994; 100: 21-30.

3 Wolfe F. The natural history of rheumatoid arthritis. J Rheumatol Suppl 1996; 44: 13-22.

4 Young A, Dixey J, Cox N, Davies P, Devlin J, Emery P, et al. How does functional disability in early rheumatoid arthritis (RA) affect patients and their lives? Results of 5 years of follow-up in 732 patients from the Early RA Study (ERAS). Rheumatol 2000; 39: 603-11.

5 Jantti J, Aho K, Kaarela K, Kautiainen H. Work disability in an inception cohort of patients with seropositive rheumatoid arthritis: a 20 year study. Rheumatology 1999; 38: 1138-41.

6 Cooper NJ. Economic burden of rheumatoid arthritis: a systematic review. Rheumatology 2000; 39: 28-33.

7 Emery P. The Roche Rheumatology Prize Lecture. The optimal management of early rheumatoid disease: the key to preventing disability. Br J Rheumatol 1994; 33: 765-8.

8 Emery P. Therapeutic approaches for early rheumatoid arthritis. How early? How aggressive? Br J Rheumatol 1995; 34 (suppl 2): 87-90.

9 Machold KP, Eberl G, Leeb BF, Nell V, Windisch B, Smolen JS. Early arthritis therapy: rationale and current approach. J Rheumatol Suppl 1998; 53: 13-9.

10 Brook A, Corbett M. Radiographic changes in early rheumatoid disease. Ann Rheum Dis 1977; 36: 71-73.

11 Fuchs HA, Kaye JJ, Callahan LF, Nance EP, Pincus T. Evidence of significant radiographic damage in rheumatoid arthritis within the first 2 years of disease. J Rheumatol 1989; 16: 585-591.

12 Kaarela K, Kautiainen H. Continuous progression of radiological destruction in seropositive rheumatoid arthritis. J Rheumatol 1997; 24: 1285-7.

13 Graudal NA, Jurik AG, de Carvalho A, Graudal HK . Radiographic progression in rheumatoid arthritis: a long-term prospective study of 109 patients. Arthritis Rheum 1998; 41: 1470-1480.

14 Drossaers-Bakker KW, de Buck M, van Zeben D, Zwinderman AH, Breedveld FC, Hazes JM. Long-term course and outcome of functional capacity in rheumatoid arthritis: the effect of disease activity and radiologic damage over time. Arthritis Rheum 1999; 42: 1854-60.

15 Symmons DP, Jones MA, Scott DL, Prior P. Longterm mortality outcome in patients with rheumatoid arthritis: early presenters continue to do well. J Rheumatol 1998; 25: 1072-7.

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