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The NICE and BSR guidelines on the management of rheumatoid arthritis

Chris Deighton Consultant Rheumatologist, Royal Derby Hospital
Raashid Luqmani Consultant Rheumatologist/Senior Lecturer, Nuffield Orthopaedic Centre/University of Oxford

Issue 4 (Hands On Series 6) Autumn 2009        Download pdf

Editorial

We have recently seen the release of two new guidelines on the management of rheumatoid arthritis and reports on rheumatoid arthritis from both The King’s Fund and the National Audit Office. The NICE guidelines have been distributed to primary care; the BSR/BHPR guidelines (covering management in established disease – a corollary to their 2006 guidelines on early rheumatoid arthritis) are available on the BSR website (www.rheumatology.org.uk).

It is often difficult to know where to look for sound clinical information, as the choice can be overwhelming. General practitioners are bombarded with well-meaning advice and it would be easy to overlook quality guidelines.

In preparing this edition of Hands On I asked the two main authors of the NICE and the BSR/BHPR guidelines to compare and contrast their own guidance and illustrate the important points of each for primary care.

Louise Warburton, Medical Editor

PS: Thank you to all the readers who took the time to complete the questionnaire accompanying the last issue of Hands On. The response was magnificent and will be most valuable.

Introduction

Two influential and informative reports have been published recently:

  • ‘Perceptions of patients and professionals on rheumatoid arthritis care’, by The King’s Fund (commissioned by the Rheumatology Futures Group),1 and
  • ‘Services for people with rheumatoid arthritis’, by the National Audit Office.2

Both reports show that, although there are examples of excellence, the provision of high-quality care for patients with rheumatoid arthritis (RA) is patchy across the UK.

The standards to which all UK services should aspire are laid out in two sets of documents:

  • the National Institute for Health and Clinical Excellence (NICE) RA management guidelines,3,4 and
  • the British Society for Rheumatology and British Health Professionals in Rheumatology (BSR/BHPR) guidelines for patients with less than 2 years of disease5 and those with more than 2 years.6

In this article we review the key messages for GPs from these guidelines, and highlight any differences between them.

Why is there a need for any guidelines in RA?

  • RA is a common disease affecting about 1% of the population, so all GPs will occasionally see new cases of RA, and will certainly be looking after a number of patients with established RA.
  • RA costs the nation a huge amount of money each year, with £560 million annually in direct care costs and total costs to the UK economy of £3.8–£4.8 billion per year.2
  • The provision of care for RA shows marked variation across the UK.1,2 If agreement could be reached on what constitutes good care, and recommendations implemented, this variation could be reduced.
  • There is now good evidence that early recognition of persistent inflammatory arthritis, and appropriate and intensive interventions, can lead to long-term benefits. The National Audit Office has shown that these interventions would be cost-saving in the long term.2 If this early ‘window of opportunity’ is missed the damage to the patient’s joints may be irreversible.
  • Previously the drug management of RA was relatively cheap, but with the advent of biological therapies the disease has the potential to consume large amounts of limited National Health Service (NHS) resources. Early intensive intervention may decrease, or at least delay, the need for patients to go onto biological therapies.

Why are there guidelines from both NICE and the BSR?

At the time when the BSR and BHPR decided it would be appropriate to put national RA guidelines together, there was no indication from NICE that they had similar plans. By the time NICE announced their plan for an RA management guideline, work on the BSR/BHPR guidelines [referred to from now on as the BSR guidelines] was well under way. There are some constraints on NICE disease-management guidelines, chiefly that evidence reviews cannot be undertaken in areas already covered by other NICE guidance such as single-technology appraisals (e.g. the guidelines could not advocate the use of anti-tumour necrosis factor (TNF) therapy before the failure of conventional disease-modifying anti-rheumatic drugs (DMARDs)). By contrast, BSR guidelines have no such constraints, and are only limited by the evidence that is available. NICE guidelines do not specify who should provide a particular service (unless it receives a particular remit to do so from the Department of Health), whereas BSR guidelines can recommend that certain individuals are best suited to some aspects of service delivery. NICE guidelines have substantially more funding than BSR guidelines, which allows for the provision of a technical team to support development, with information scientists, research fellows, health economists and project managers. BSR guidelines rely more on the goodwill and enthusiasm of a multidisciplinary team. NICE guidelines can commission new health economic research to determine the cost-effectiveness of interventions, whereas BSR guidelines have not usually taken this route. In some regards this places fewer constraints on BSR guidelines in that recommendations can be made largely on clinical grounds, with less concern about health economic issues. In other regards, as the NICE guidelines have taken cost-effectiveness into account they may therefore have more credibility with commissioners when implementation is being discussed. Finally, NICE guidelines will usually have more influence with commissioners than professional society guidelines.

So do the NICE RA guidelines render the BSR guidelines redundant?

No guideline can ever cover the whole of the management of a disease, and the two RA guidelines complement each other in being more detailed in some areas than others, with different emphases. The two should therefore be read as guidelines that overlap with each other, and by no means cancel each other out. When one of us (Chris Deighton) was appointed as Clinical Adviser to the NICE RA guidelines, he was keen to ensure that all of the hard work and accrued knowledge that had gone into the BSR guidelines would be available to the NICE process. He was therefore pleased when the lead for the BSR guidelines (Raashid Luqmani) applied to join and was appointed to the NICE Guideline Development Group. This was along with Sheena Hennell (nurse consultant), Ailsa Bosworth (patient representative and Chief Executive of the National Rheumatoid Arthritis Society) and Louise Warburton (GP with a special interest in rheumatology), who were also key members of both guideline groups. It is therefore little surprise that the guidelines overlap with each other.

What are the key messages for GPs from the two guidelines?

1.    There is a need for early diagnosis of RA, and rapid referral to specialist care. Both guidelines seek to define when transient joint pain and swelling becomes something which needs further action by the GP. The NICE guidelines have been criticised for the technical terms in the recommendation, referring to ‘suspected persistent synovitis of undetermined cause’; the BSR guidelines talk about persistent joint inflammation. Neither defines what is meant by ‘persistent’, but they agree that if there is involvement of small joints of the hands and feet, then referral should be urgent. Both guidelines acknowledge that this is not straightforward for GPs, given the lack of diagnostic tests for early RA. This remains a clinical diagnosis, where the detection of synovitis can be challenging. There is a need for GPs to exercise a low level of suspicion for RA. Within the literature reviewed for the NICE guidelines, there is discussion of the evidence that if a squeeze across the metacarpal or metatarsal joints is uncomfortable for the patient, this should be sufficient to raise concern and trigger a referral. The BSR guidelines emphasise the importance of morning stiffness of joints as a useful clinical marker of early disease.

2.    There is a need for early intensive treatment of active RA. The NICE guidelines recommend combination therapies from the start of such disease, with the BSR guidelines placing a strong emphasis on the evidence for this approach as part of an ‘aggressive package of care’. The NICE guidelines had the advantage of being able to commission a new health economic analysis which showed that a combination therapy was more cost-effective than sequential monotherapy, with a step-down approach (starting with combinations immediately, then gradually cutting them down) being more cost-effective than a step-up approach (starting with monotherapy and then adding to this). Although the American College of Rheumatology (ACR) criteria for RA perform poorly in diagnosing early disease, they do identify patients with a poor prognosis if they fulfil the criteria7 (see Table 1). Because trials of combination therapies have taken place in people with RA identified according to the ACR criteria, and because these patients all had to have ‘active’ disease (defined differently in different trials) to enter the trial, the NICE guidelines refer specifically to this more restricted group, and not to all early inflammatory arthritis patients.

TABLE 1. Summary of the American College of Rheumatology 1987 classification criteria for rheumatoid arthritis.7

Patients must have four of seven criteria:

  • Morning stiffness lasting at least 1 hour*
  • Swelling in 3 or more joints*
  • Swelling in hand joints*
  • Symmetrical joint swelling*
  • Erosions or periarticular osteopaenia on hand x-rays
  • Rheumatoid nodules
  • Abnormal serum rheumatoid factor

*must have been present for at least 6 weeks

Because of the evidence for a ‘window of opportunity’ in which disease-modifying interventions may exert long-term benefits, the NICE recommendation specifies that drugs to slow the disease down should be introduced within 3 months of symptom onset, but both guidelines agree that such drugs should be introduced as soon as possible. Both guidelines acknowledge that steroids have a role in suppressing early disease, but specify that their long-term use should be avoided whenever possible.

3.    There is a need to document early disease so that the response to therapy can be monitored. The NICE guidelines were influenced by those impressive intensive approaches that have followed up patients on a monthly basis, measure disease activity with a composite index such as the disease activity score DAS288 (see Figure 1) and act on unacceptably high disease activity, and they included this as part of their recommendation. The BSR guidelines emphasise the need for assessment of response and defining remission, and planning reduction of DMARDs if this is achieved. The NICE guidelines do not specify aiming for remission but prefer the phrase ‘controlled the disease to a level previously agreed with the person with RA’, acknowledging the need for ongoing dialogue between the patient and the multidisciplinary team in deciding what is best for each person.

4.    Both documents recommend ongoing access to the multidisciplinary team, and the skills that each member can provide to help the person with RA. Both the NICE and the BSR guidelines recommend a more patient-friendly approach with regard to follow-ups, seeing patients when the patient feels it is most appropriate (and urgently for flares of disease or other emergencies) rather than when it is convenient for the clinic. They also both support the introduction of an annual review, incorporating aspects of disease management, joint damage (not forgetting the cervical spine), functional outcomes, patient goals and evaluation of co-morbidities such as cardiovascular disease, osteoporosis and depression.

Note: It is well established, although not widely known, that the cardiovascular risk for patients with RA is similar to that in diabetes mellitus type 2, with atherosclerotic heart disease accounting for a 1.5–2-fold increased risk of death and occurring a decade earlier in patients with RA compared to the general population. 

Although the use of annual review in established RA is advocated by both guidelines, few rheumatologists have implemented this. This may in part be due to the lack of evidence for its benefit, and uncertainty about the best approach to providing such a service. More research is needed to identify the most effective ways of providing this annual structured overview. There also needs to be coordination between primary and secondary care, to ensure there is no duplication of activities or omission because one party assumes the other is responsible for conducting an aspect of review. Because cardiovascular risk for some patients will be covered by Quality and Outcomes Framework (QOF) points, it may be that GPs are ideally placed to perform this aspect of annual review. There is no need for the whole of annual review to be conducted in one place and at one clinic visit, as long as there is coordination of efforts between the caring agencies, and communication of the results.

Where can GPs turn to for quick up-to-date advice on managing RA?

There is an inevitable timelag between publication of new guidelines and the updating of secondary documentation, so if readers also wish to make use of GP information systems such as Patient UK (http://www.patient.co.uk/ ) or the Map of Medicine (http://healthguides.mapofmedicine.com/ ) always check the date of publication of the individual pages consulted.

What might GPs consider auditing to demonstrate that they are providing a high-quality service for their RA patients?

In a separate document (a support tool for clinical audit based on the NICE guidance)9 NICE suggests some useful projects concerning percentages of people with suspected synovitis who are referred for specialist opinion, and the percentage referred urgently if the small joints of the hands or feet are affected, or more than one joint is affected; or if there has been a delay of 3 months or longer between onset of symptoms and seeking medical advice (see http://guidance.nice.org.uk/CG79/AuditCriteria/doc/English for the full document). The NICE suggestions for audit do not cover established RA from a primary care perspective, but aspects of shared care and of the annual review, such as cardiovascular risk assessment, might be considered for audit projects to ensure that a high-quality service is being provided.

Summary

In summary, the NICE and BSR/BHPR guidelines provide complementary recommendations on high-quality services for people with this disease. Figure 2 provides a useful overview. There are considerable overlaps between the two guidelines, and where there are differences these are more in emphasis rather than significant disagreements. If the recommendations from both guidelines could be implemented, the quality of care for people with RA would improve substantially.

Disclaimer

This article is the view of the authors and does not necessarily represent the views of the National Institute for Health and Clinical Excellence or the British Society for Rheumatology/British Health Professionals in Rheumatology.

References

1. The King’s Fund. Perceptions of patients and professionals on rheumatoid arthritis care. London; 2009.
http://www.rheumatoid.org.uk/article.php?article_id=615.

2. National Audit Office. Services for people with rheumatoid arthritis. London: The Stationery Office; 2009. http://www.nao.org.uk/publications/0809/rheumatoid_arthritis.aspx.

3. National Institute for Health and Clinical Excellence. Clinical Guideline 79. Rheumatoid arthritis 2009 Feb.

4. Deighton C, O’Mahony R, Tosh J, Turner C, Rudolf M; Guideline Development Group. Management of rheumatoid arthritis: summary of NICE guidance. http://www.bmj.com/cgi/content/full/338/mar16_1/b702.

5. Luqmani R, Hennell S, Estrach C et al; BSR and BHPR Standards, Guidelines and Audit Working Group. British Society for Rheumatology and British Health Professionals in Rheumatology guideline for the management of rheumatoid arthritis (the first 2 years). 2006.

6. Luqmani R, Hennell S, Estrach C et al; BSR and BHPR Standards, Guidelines and Audit Working Group. British Society for Rheumatology and British Health Professionals in Rheumatology guideline for the management of rheumatoid arthritis (after the first 2 years). 2009.

7. Arnett FC, Edworthy SM, Bloch DA et al. The American Rheumatism Association 1987 revised criteria for the classification of rheumatoid arthritis. Arthritis Rheum 1988;31(3):315-24.

8. DAS-score.nl. http://www.das-score.nl/www.das-score.nl/.

9. National Institute for Health and Clinical Excellence. Rheumatoid arthritis. Audit support: implementing NICE guidance. 2009. http://guidance.nice.org.uk/CG79/AuditCriteria/doc/English

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