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S I G N

PROPOSAL FOR INCLUSION IN SIGN GUIDELINE DEVELOPMENT PROGRAMME

Proposed title of clinical guideline

Management of Early Rheumatoid Arthritis

Summary of the clinical problems and outcomes to be addressed

Disease modifying therapies are often initiated too late in the course of RA to achieve maximal benefit. Early functional outcome as well as medium and long term functional ability is better in patients where DMARDS are initiated early.

Contact person(s) proposing topic for guideline development

H A Capell, R Madhok, E Morrison

Group(s) or institution(s) supporting the proposal

Centre for Rheumatic Diseases, Royal Infirmary, and Rheumatology Department, Southern General Hospital, Glasgow

Provide a brief background to the clinical topic which will be addressed by the proposed guideline. This should include a description of the clinical importance of the topic in terms of its appropriateness for inclusion in the SIGN programme (e.g. targeted patient group(s), interventions, outcomes, evidence of variations in practice).

Rheumatoid arthritis affects 1:100 of the population and is a significant cause of morbidity and premature mortality. There has been increasing recognition of the need for early intervention with disease modifying therapy to reduce the adverse impact on patients and on the community. The majority of patients with early RA are seen by general practitioners (primary care physicians) not all of whom will be aware of the recent rheumatological literature. In addition, general physicians and orthopaedic surgeons often have a major input into the care of RA patients where rheumatology services are in short supply and they too may be unaware of recent developments.

Indicate the benefits likely to arise from the development and successful implementation of the guideline. This should include a description of potential improvements in patient outcomes or in the use of resources.

Early referral of patients thought to have RA and early initiation of DMARD therapy should reduce the functional impairment in RA and slow progression of disease. This will have a beneficial effect for the patient, their family and work colleagues as well as the community as a whole. Patients with less impairment of function utilise fewer resources.

Indicate the health care professionals potentially involved in developing the guideline.

Most DMARD therapy in RA is administered on a shared care basis. The Centre for Rheumatic Diseases runs regular general practitioner teaching courses and liaison with general practitioner colleagues in devising guidelines would be of importance.

What is the likelihood of producing a guideline which includes Grade A or Grade B recommendations? Please cite key papers which support your estimate.

Key papers noted below:

Effectiveness of early treatment with "second-line" antirheumatoid drugs. A randomised controlled trial. Van der Heide A et al. Ann Int Med 1996;124 (8):699. Grade A.

Improved functional outcome in patients with rheumatoid arthritis treated with intramuscular gold: Results of a five year prospective study. Munro R, Hampson R, McEntegart A, Thomson EA, Madhok R, Capell HA. Ann Rheum Dis 1998 (in press) Grade B.

Reduction in long term disability in patients with rheumatoid arthritis by disease modifying antirheumatic drug based treatment strategies. Fries J et al. Arth & Rheum 1996; 39 (4): 616-622. Grade B.

Rheumatoid arthritis: Treat Now, Not Later! Weinblatt M. Ann Intern Med 1996; 124: 773-4. Grade C. Continuous progression of radiological destruction in seropositve rheumatoid arthritis. Kaarela K, Kautiainen H. J Rheumatol 1997; 24: 1285-7. Grade B.

Evidence of significant radiographic damage in rheumatoid arthritis within the first two years of disease. Fuchs HA et al. J Rheumatol 1989; 16: 585-91. Grade B.

Please identify any existing guideline or systematic review that you are aware of which could inform the proposed development process in Scotland

American College of Rheumatology Guidelines for the Management of Rheumatic Arthritis. Arth & Rheum 1996; 39 (5): 713-22.

10.

Provide any further information which you would like to be considered (e.g. audit programme)

The West of Scotland is undertaking a study of early rheumatoid and the use of low dose steroid against placebo (WOSERACT). The use of steroids is an additional confounding factor but the evidence is not sufficiently clear-cut at present for this aspect to be part of the SIGN guidelines.

Thank you for completing this form. Please return to the SIGN Secretariat, Royal College of Physicians, 9 Queen Street, Edinburgh EH2 1JQ.