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RHEUMATOID ARTHRITIS
Criteria Area
The Management of Rheumatoid Arthritis Rheumatoid Arthritis (RA) has a prevalence of about 1% in females and 0.7% in males. The management of this condition truly requires a team approach; the use of agreed protocols across primary and secondary care and the involvement of a variety of practitioners are essential to deliver appropriate care. There is no single diagnostic test. Investigations are used largely to support the clinical diagnosis and negative tests do not exclude a diagnosis of rheumatoid arthritis. Rheumatoid factor, for example, is positive in only 70% - 75% of cases of RA at some time in their disease course. This criteria set is particularly relevant to the management of patients with inflammatory arthritis of the rheumatoid type, requiring disease modifying anti-rheumatic drugs (DMARD). Patients registered for inclusion will normally have had their diagnosis confirmed by, and their treatment plan agreed with, a secondary care rheumatology specialist.

Summary list of criteria

1. The practice should maintain a database of patients with rheumatoid arthritis. 2. In newly diagnosed patients the diagnosis should involve input from a rheumatology specialist. 3. The number of patients on long term oral steroids will be identified. 4. Appropriate osteoporosis prophylactic therapy will be offered to those on long term steroids. 5. The number of patients receiving parenteral or intra-articular steroids in the last year will be recorded. 6. DMARD should be monitored for both efficacy and toxicity according to local guidelines. Patients are required to have their therapy assessed from a toxicity aspect monthly for some drugs and at least every three months. 7. Physiotherapy referral will be offered. 8. Podiatry referral will be offered where the patient has foot problems. 9. Influenza vaccine will be offered in accordance with national CMO guidance.

Revised March 2004

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SPICE PC

Rationale Behind Choice of Criteria

Database A database of patients with a diagnosis is essential for chronic disease management, allowing identification and benchmarking. Criterion 1 The practice should maintain a database of patients with rheumatoid arthritis.

Diagnosis The implications of a diagnosis of rheumatoid arthritis and its management are considerable. Diagnostic accuracy is not without difficulty. History, clinical signs and investigations can all be misleading. The diagnosis should normally be made definitively by a rheumatology specialist. Criterion 2 In newly diagnosed patients the diagnosis should involve input from a rheumatology specialist.

Oral corticosteroids It is to be hoped that as few patients as possible will require long-term oral steroid therapy, and these patients may require particular attention. Criterion 3 The number of patients on long-term oral steroids will be identified.

Osteoporosis prophylaxis Patients on long-term steroid therapy (7.5mg daily or greater for more than six months) may require prophylaxis against osteoporosis. Criterion 4 Appropriate osteoporosis prophylactic therapy will be offered to those on long term steroids.

Steroid therapies from different sources Some patients receive parenteral steroid therapy, perhaps from a variety of sources. The supervising clinician should be aware of the frequency of parenteral steroid administration. Intra-articular injections can offer rapid and sustained symptomatic relief in target joints. Intra-articular injections to any one joint should not be given more than three times per year. Criterion 5 The number of patients receiving parenteral or intra-articular steroids in the last year will be recorded.

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RCGP (Scotland)

Revised March 2004

Rheumatoid Arthritis

Monitoring of DMARDs DMARDs are the cornerstone of the pharmacological management of RA. Early initiation and sustained input is vital if disease suppression is to be maintained. Cure is seldom achieved thus withdrawal of therapy is seldom appropriate. For patients on DMARDs, regular monitoring of efficacy and toxicity is essential. Criterion 6 DMARD should be monitored for both efficacy and toxicity according to local guidelines. Patients are required to have their therapy assessed from a toxicity aspect monthly for some drugs and at least every three months.

Physiotherapy The role of physiotherapy in the management of RA is well recognised. Specific intervention may be required from time to time. Patients should be encouraged to undertake simple dynamic exercises. The nature of these is best demonstrated by a physiotherapist. Criterion 7 Physiotherapy referral will be offered.

Podiatry The importance of appropriate footwear provision and foot care is well recognised. Criterion 8 Podiatry referral will be offered where the patient has foot problems.

Influenza vaccination In line with current national guidance, as for any chronic disease, influenza vaccination will be offered annually Criterion 9 Influenza vaccine will be offered in accordance with national CMO guidance.

Revised March 2004

RCGP (Scotland)

18-3

SPICE PC

Data Collection and Benchmarking

Criterion 1 Practices will record the diagnosis of rheumatoid arthritis. Results will be fed back as the percentage of the practice population with a diagnosis of rheumatoid arthritis. Criterion 2 Practices will record the referral of patients with rheumatoid arthritis to a specialist. Results will be fed back as the percentage of rheumatoid arthritis patients with a record of referral to a specialist. Criterion 3 Practices will record the prescribing of oral steroids. The results will be fed back as the percentage of patients with a diagnosis of rheumatoid arthritis who are being prescribed maintenance oral steroids. Criterion 4 Practices will record the provision of osteoporosis treatment in patients with rheumatoid arthritis. Results will be fed back as the proportion of patients with rheumatoid arthritis receiving osteoporosis treatment. Criterion 5 Practices will record parenteral steroid treatments. Results will be fed back as the percentage of patients with steroid injections and the number of injections in the preceding years. Criterion 6 Practices will record the monitoring of disease modifying drugs. The results will be fed back as the percentage of rheumatoid patients on DMARDS who have had a review within the preceding three months. Criterion 7 Practices will record referrals to physiotherapy of patients with rheumatoid arthritis. The results will be fed back as the proportion of rheumatoid patients referred for physiotherapy. Criterion 8 Practices will record referrals to podiatry. Results will be fed back as the proportion of patients referred to podiatry. Criterion 9 Practices will record influenza immunisations. The results will be fed back as the proportion of patients receiving influenza immunisation.

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RCGP (Scotland)

Revised March 2004

Rheumatoid Arthritis

Criteria set revised 2004

Membership of the original working group John Haughney (Chair) Barbara Black William Brandon Hilary Capell Joe Cassidy William Graham Gillian Hosie Darryl McGhee Sharon Wiener-Ogilvie Reference material SIGN Publication 48; December (2000), The early management of rheumatoid arthritis. RCGP Quality Initiative Adviser, GP East Kilbride Senior II Physiotherapist, Medical Rehabilitation Unit, Uddingston Lay member, Uddingston Consultant Rheumatologist, Glasgow Royal Infirmary, Chair SPICE 48 GP , Johnstone (post graduate deans representative) GP , Glasgow GP , Glasgow, past president Primary Care Rheumatology Society Rheumatology Liaison Sister, Southern General Hospital, Glasgow Podiatrist, Hairmyres Hospital, East Kilbride

Revised March 2004

RCGP (Scotland)

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