Changes

April 2025 — minor update. QOF indicators removed in line with NHS England's 2025 Quality and Outcomes Framework.

Update

Goals

To support primary healthcare professionals to:

• Recognize suspected rheumatoid arthritis (RA).
• Make an accurate assessment of someone with RA.
• Refer all people with suspected RA to a specialist for diagnosis, treatment, and follow-up.
• Give appropriate treatment for a flare of RA in primary care.
• Provide appropriate advice and support to people with RA.

Outcome measures

Audit criteria

QOF indicator

No QOF indicators were found during the review of this topic.

QIPP - Options for local implementation

Non-steroidal anti-inflammatory drugs (NSAIDs)

• Review the appropriateness of NSAID prescribing widely and on a routine basis, especially in people who are at higher risk of both gastrointestinal (GI) and cardiovascular (CV) morbidity and mortality (for example, older patients).
• If an NSAID is needed, use ibuprofen (1,200 mg a day or less) or naproxen (1,000 mg a day or less). Use the lowest effective dose and the shortest duration of treatment necessary to control symptoms.
• Co-prescribe a proton pump inhibitor (PPI) with NSAIDs for people with osteoarthritis and rheumatoid arthritis, and think about the use of gastroprotective treatment when prescribing NSAIDs for low back pain, axial spondyloarthritis, psoriatic arthritis and other peripheral spondyloarthritides.

[NICE, 2020a]

NICE quality standards

• Adults with suspected persistent synovitis affecting more than 1 joint, or the small joints of the hands and feet, are referred to rheumatology services within 3 working days of presenting in primary care.
• Adults with active rheumatoid arthritis start conventional disease-modifying anti-rheumatic drug (cDMARD) monotherapy within 6 weeks of referral, with monthly monitoring until their treatment target is met.
• People with suspected persistent synovitis are assessed in a rheumatology service within 3 weeks of referral.
• Adults with rheumatoid arthritis are given opportunities throughout the course of their disease to take part in educational activities that support self-management.
• Adults with rheumatoid arthritis and disease flares or possible treatment-related side effects receive advice within 1 working day of contacting rheumatology services.
• Adults with rheumatoid arthritis have a comprehensive annual review that is coordinated by rheumatology services.
• People with rheumatoid arthritis and disease flares or possible drug-related side effects receive advice within 1 working day of contacting the rheumatology service.
• People with rheumatoid arthritis have a comprehensive annual review that is coordinated by the rheumatology service.

[NICE, 2020b]

What is it?

• Rheumatoid arthritis (RA) is a chronic systemic inflammatory disease. Early RA is defined as a disease duration of 5 years or less from the onset of symptoms.
• RA is a heterogeneous disease which arises not only from genetic and epigenetic components but also from significant environmental factors such as cigarette smoke [Scherer, 2020].
  
  • RA presents as inflammatory arthritis typically affecting the small joints of the hands and the feet, and usually, both sides equally and symmetrically, although any synovial joint can be affected. 
  • As RA progresses, any system of the body may be affected by the underlying inflammatory process, leading to an increased risk of premature death.
  • RA is associated with a number of complications and comorbidities.

[BMJ Best Practice, 2023; Chauhan, 2023]

How common is it?

• The prevalence of confirmed rheumatoid arthritis (RA) is about 1% of the UK population (similar to worldwide prevalence). It is the most common inflammatory arthritis.
  • The incidence of the condition is low, with around 1.5 men and 3.6 women developing RA per 10,000 people per year in the UK.
  • RA onset can occur at any age but peaks between people aged 30–50 years. 
  • The peak age of incidence in the UK for both men and women is in the 70s.
• RA is 2–4 times more common in women than in men.
• Family history confers a two to four-fold increase in risk for first-degree relatives.
• Approximately one third of people stop work because of RA within 2 years of its onset, and this increases thereafter.

  [Wasserman, 2018; Hazlewood, 2022; BMJ Best Practice, 2023; Chauhan, 2023]

What are the complications?

• Complications of rheumatoid arthritis (RA) include:
  • Amyloidosis. 
  • Anaemia.
  • Dry eye syndrome (keratoconjunctivitis sicca), peripheral ulcerative keratitis.
  • Felty's syndrome (enlarged spleen and low white blood cell count) — this affects fewer than 1% of people with RA. 
  • Fatigue. 
  • Increased mortality.
  • Interstitial lung disease, pleural effusion, fibrosing alveolitis. 
  • Neuropathy.
  • Orthopaedic problems, for example:
    • Carpal tunnel syndrome — typically around 10–20% of people with RA, although rates as high as 29% have been reported. 
    • Increased joint replacement surgery.
    • Tendon rupture.
    • Cervical myelopathy.
  • Vasculitis, vasculitic ulcers, rheumatoid nodules.
  • Weight loss.
• Severe disease is also associated with comorbidities, including:
  • Cardiovascular disease – accelerated atherosclerosis is the leading cause of death in people with RA. Pericarditis is present in 30-50% of people with RA on autopsy but rarely leads to tamponade. 
  • Depression. 
  • Lymphomas — the risk is double in people with RA, independent of immunosuppressant use.
  • Serious infections. 
• Complications associated with drug treatment include:
  • Gastrointestinal problems — mainly due to the adverse effects of nonsteroidal anti-inflammatory drugs (NSAIDs).
  • Infection — glucocorticoids and immunosuppressants increase the risk of infection.
  • Liver toxicity — methotrexate-related. 
  • Malignancy — particularly TNF-alpha inhibitor-related (increased risk of skin cancer). 
  • Osteoporosis — low-dose glucocorticoid use in people with RA reduces bone mineral density and increases the risk of fractures. RA also increases the risk of osteoporosis in the absence of glucocorticoid use.

 [Simon, 2015; Smolen, 2016; Heinlen, 2017; England, 2018; Wasserman, 2018; NICE, 2020a; BMJ Best Practice, 2023; Chauhan, 2023]

When should I suspect rheumatoid arthritis?

• Suspect rheumatoid arthritis (RA) in anyone with persistent synovitis, where no other underlying cause is obvious (for example, psoriatic arthritis). 
  • Clinical judgement should be used to decide if the synovitis is 'persistent' (lasting a few weeks rather than days).
• RA typically causes symmetrical synovitis of the small joints of the hands and feet, although any synovial joint may be affected. Clinical features of synovitis include:
  • Pain, swelling, heat and stiffness in affected joints.
    • Pain — usually, this is worse at rest or during periods of inactivity.
    • Swelling — around the joint (not bone swelling), giving a 'boggy' feel on palpation. 
    • Stiffness — early morning stiffness usually lasts over 1 hour (a history of prolonged morning stiffness is more helpful when forming a diagnosis than currently having morning stiffness for early RA).
• Persistent synovitis and a poorer prognosis is more likely when:
  • A greater number of joints are affected (the more joints, the worse the prognosis). 
  • There is swelling and tenderness in the affected joints (particularly small joints). 
  • The proximal interphalangeal joints and metacarpophalangeal joints are affected, and there is symmetry of affected joints. 
  • There is a positive metacarpophalangeal squeeze test – pain on squeezing the metacarpophalangeal or metatarsophalangeal joints together.
• An inability to make a fist or flex fingers is associated with an ability to diagnose RA from other diagnoses.
• In addition to joint synovitis, RA may present with:
  • Rheumatoid nodules — hard, firm swellings over extensor surfaces occur in a third of people with RA. 
  • Extra-articular features such as vasculitis or involvement of other body systems (for example, eye, lungs, and heart).
  • Systemic features of malaise, fatigue, fever, sweats, and weight loss. 
  • A family history of RA. 
• The presentation of RA is variable. Most people have an insidious onset, but others can have a rapid or relapsing and remitting course (such as a palindromic presentation). 

What else might it be?

• Other conditions that may cause synovitis include:
  • Connective tissue disorders — for example, systemic lupus erythematosus (SLE). There may be polyarthritis in the small joints of the hands and feet, but SLE arthritis is usually non-deforming. Suspect this if there are additional signs and symptoms (for example, rash, mouth ulcers, alopecia, Raynaud's syndrome or Sicca syndrome). 
  • Fibromyalgia — suspect if numerous myofascial trigger points and somatic symptoms are present.
  • Infectious arthritis (viral or bacterial) — suspect this if the person has an ongoing infection. Direct infection of a joint is rare. Seek urgent specialist advice if it is suspected.
  • Osteoarthritis — for more information, see the CKS topic on Osteoarthritis. 
  • Polyarticular gout — suspect this if the person has risk factors for gout or visible tophi. For more information, see the CKS topic on Gout.
  • Polymyalgia rheumatica — suspect this if the main symptoms are shoulder pain and stiffness. For more information, see the CKS topic on Polymyalgia rheumatica. 
  • Psoriatic arthritis — commonly involves small joints of the hands and feet, but is less often symmetrical. Unlike rheumatoid arthritis, the distal interphalangeal joints may be involved. Psoriasis is present in over 90% of people with psoriatic arthritis. 
  • Reactive arthritis — suspect this if the person has recently had a viral or bacterial infection. There is no direct infection in the joint, but it can cause symmetric hand and foot arthritis.
  • Sarcoidosis — chest X-ray may be helpful if this is suspected.
  • Septic arthritis — suspect this if a single joint is hot and swollen, especially if there are signs of sepsis (such as fever).
  • Seronegative spondyloarthritis — suspect this if there is a history of psoriasis, back pain, or bowel problems.

What investigations are necessary for suspected rheumatoid arthritis?

• There is no specific diagnostic test for rheumatoid arthritis (RA). The diagnosis is clinical. Refer all people suspected of having RA for specialist assessment.
• If RA is suspected clinically, investigations are not necessary in primary care. However, consider the following tests to speed up the diagnostic process:
  • Offer to carry out a blood test for rheumatoid factor — this is present in 60–70% of people with RA.
  • Consider measuring anti-cyclic citrullinated peptide (anti-CCP) antibodies in people if they are negative for rheumatoid factor — these are found in about 80% of people with RA.
  • Arrange X-rays of the hands and feet — these help with diagnosis and determination of disease severity.
• Consider the following tests to speed up the diagnostic process and to act as a baseline measure prior to treatment: 
  • Full blood count, renal and liver function tests — these will help guide treatment and identify any relevant comorbidities.
  • C-reactive protein or erythrocyte sedimentation rate — inflammatory markers are usually, but not always, elevated in RA (up to 40% of people with RA may have normal levels). 
  • Ultrasound or magnetic resonance imaging (MRI) of joints — depending on local policy and availability. 
• Do not let investigations delay a referral for clinically suspected RA. 

Scenario: Suspected rheumatoid arthritis

From age 16 years onwards.

Scenario: Confirmed rheumatoid arthritis

From age 16 years onwards.

Search strategy

Scope of search

A literature search was conducted for guidelines and systematic reviews on primary care management of rheumatoid arthritis.

Search dates

August 2013 - December 2018

Key search terms

The terms listed below are the core search terms that were used for EBSCOhost MEDLINE (searched 17th December 2018). These terms were combined with search filters for systematic reviews and guidelines in EBSCOhost MEDLINE. The strategy was adapted for The Cochrane Library databases. 

S3    S1 OR S2
S2    AB rheumatoid arthritis OR TI rheumatoid arthritis
S1    (MH "Arthritis, Rheumatoid+")

Sources of guidelines

• National Institute for Health and Care Excellence (NICE)
• Scottish Intercollegiate Guidelines Network (SIGN)
• Royal College of Physicians
• Royal College of General Practitioners
• Royal College of Nursing
• NICE Evidence
• World Health Organization
• Guidelines International Network
• TRIP database
• Agency for Healthcare Research and Quality
• National Health and Medical Research Council (Australia)
• Royal Australian College of General Practitioners
• British Columbia Medical Association
• Canadian Medical Association
• Alberta Medical Association
• Michigan Quality Improvement Consortium
• Singapore Ministry of Health
• National Resource for Infection Control
• RefHELP NHS Lothian Referral Guidelines
• Medline (with guideline filter)
• Driver and Vehicle Licensing Agency
• NHS Health at Work (occupational health practice)

Sources of systematic reviews and meta-analyses

• The Cochrane Library:
  • Systematic reviews
  • Protocols
  • Database of Abstracts of Reviews of Effects
• Medline (with systematic review filter)
• EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

• NIHR Health Technology Assessment programme
• The Cochrane Library:
  • NHS Economic Evaluations
  • Health Technology Assessments
• Canadian Agency for Drugs and Technologies in Health
• International Network of Agencies for Health Technology Assessment

Sources of randomized controlled trials

• The Cochrane Library:
  • Central Register of Controlled Trials
• Medline (with randomized controlled trial filter)
• EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

• Drug and Therapeutics Bulletin
• TRIP database
• Central Services Agency COMPASS Therapeutic Notes

Sources of national policy

• Department of Health
• Health Management Information Consortium (HMIC)

Patient experiences

• Healthtalk
• BMJ - Patient Journeys

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

• British National Formulary (BNF)
• electronic Medicines Compendium (eMC)
• European Medicines Agency (EMEA)
• Medicines and Healthcare products Regulatory Agency (MHRA)
• REPROTOX
• Scottish Medicines Consortium
• Stockley's Drug Interactions
• TERIS
• TOXBASE
• Micromedex
• UK Medicines Information

Stakeholder engagement

Our policy

The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:

• Clinical accuracy.
• Consistency with other providers of clinical knowledge for primary care.
• Accuracy of implementation of national guidance (in particular NICE guidelines).
• Usability.

Principles of the consultation process

• The process is inclusive and any individual may participate.
• To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.
• Comments received after the deadline will be considered, but they may not be acted upon before the clinical topic is issued onto the website.
• Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.
• External reviewers are not paid for commenting on the draft topics.
• Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
• All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.
• All reviewers are invited to be acknowledged on the website. All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.

Stakeholders

• Key stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.
• Stakeholders identified from the following groups are invited to review draft topics:
  • Experts in the topic area.
  • Professional organizations and societies (for example, Royal Colleges).
  • Patient organizations, Clarity has established close links with groups such as Age UK and the Alzheimer’s Society specifically for their input into new topic development, review of current topic content and advice on relevant areas of expert knowledge.
  • Guideline development groups where the topic is an implementation of a guideline.
  • The British National Formulary team.
  • The editorial team that develop MeReC Publications.
• Reviewers are provided with clear instructions about what to review, what comments are particularly helpful, how to submit comments, and declaring interests.

Patient engagement

Clarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:

• Topic selection
• Scoping of topic
• Selection of clinical scenarios
• First draft internal review
• Second draft internal review
• External review
• Final draft and pre-publication

Our lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals.

Evidence exclusion criteria

Our policy

Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.

Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

Standard exclusions for scoping literature:

• Animal studies
• Original research is not written in English

Possible exclusions for reviewed literature:

• Sample size too small or study underpowered
• Bias evident or promotional literature
• Population not relevant
• Intervention/treatment not relevant
• Outcomes not relevant
• Outcomes have no clear evidence of clinical effectiveness
• Setting not relevant
• Not relevant to UK
• Incorrect study type
• Review article
• Duplicate reference

Organizational, behavioural and financial barriers

Our policy

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

• Feasibility
  • Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
• Organizational and Financial Impact Analysis
• Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
  • Eligible population
  • Current interventions
  • Likely uptake of new intervention or recommendation
  • Cost of the current or new intervention mix
  • Impact on other costs
  • Condition-related costs
  • In-direct costs and service impacts
  • Time dependencies
• Cost-effectiveness or cost-benefit analysis studies are identified where available. 

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

Declarations of interest

Our policy

Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

• Personal financial interests
• Personal family interest
• Personal non-financial interest
• Non-personal financial gain or benefit

Although particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons. An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.

Who should declare competing interests?

Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.

Competing interests declared for this topic:

None.