Guidelines

Abstract

The EULAR recommendations for the management of early arthritis were published in 2007 (Combe et al. 2007). The steering group consisted of 14 rheumatologists from 10 European countries. A total of 15 issues were selected for further research by the group, which based its recommendations on the available evidence as at January 2005 and on expert opinion. The guidelines contain 12 key recommendations for the management of early arthritis, including early rheumatoid arthritis:

• Arthritis is characterised by the presence of joint swelling, associated with pain or stiffness. Patients presenting with arthritis of more than one joint should be referred to, and seen by, a rheumatologist, ideally within 6 weeks of symptom onset.

• Clinical examination is the method of choice for detecting synovitis. In doubtful cases, ultrasound, power Doppler, and MRI might be helpful.

• Exclusion of diseases other than rheumatoid arthritis requires careful history taking and clinical examination, and ought to include at least the following laboratory tests: full blood cell count, urinanalysis, transaminases, and antinuclear antibodies.

• In every patient presenting with early arthritis to the rheumatologist, the following factors predicting persistent and erosive disease should be measured: number of swollen and tender joints, ESR or CRP, levels of rheumatoid factor and ACPA, and radiographic joint erosions.

• Patients who are at risk of developing persistent or erosive arthritis should be started with DMARDs as early as possible, even if they do not yet fulfil established classification criteria for inflammatory rheumatological diseases.

• Patient information concerning the disease and its treatment and outcome is important. Education programmes aimed at coping with pain, disability, and maintenance of the ability to work may be used as adjunct interventions.

• NSAIDs have to be considered in symptomatic patients after evaluation of gastrointestinal, renal, and cardiovascular status.

• Systemic corticosteroids reduce pain and swelling and should be considered as adjunctive treatment (mainly temporary), as part of the DMARD strategy. Intra-articular corticosteroid injections should be considered for the relief of local symptoms of inflammation.

• Among the DMARDS, methotrexate is considered to be the anchor drug, and should be used first in patients at risk of developing persistent disease.

• The main goal of DMARD treatment is to achieve remission. Regular monitoring of disease activity and adverse events should guide decisions on choice and changes in treatment strategies (DMARDs here including biologic agents).

• Non-pharmaceutical interventions such as dynamic exercises, occupational therapy, and hydrotherapy can be applied as adjuncts to pharmaceutical interventions in patients with early arthritis.

• Monitoring of disease activity should include tender and swollen joint count, patient’s and physician’s global assessments, ESR, and CRP. Arthritis activity should be assessed at intervals of 1–3 months, for as long as remission is not achieved. Structural damage should be assessed by radiographs of hands and feet every 6–12 months during the first few years. Functional assessment can be used to complement this monitoring.