Guidelines of

rheumatology care
Aashish Nepal, MPT
  Rheumatology is the study and practice of medical immunology,
mainly dealing with immune-mediated disorders of the MSK
Introduction system, soft tissues, autoimmune disorders, vasculitides and
heritable connective tissue disorders.
 • Axial Spondyloarthritis

Rheumatic • Extrarenal Lupus

• Gout
disorders • Juvenile Idiopathic Arthritis
of interest • Lupus Nephritis

in • Lyme Disease
• Osteoarthritis
medicine • PMR (Polymyalgia Rheumatica)
• Psoriatic Arthritis
• Reproductive Health in Rheumatic Diseases
• Rheumatoid Arthritis
• Vasculitis
  National Institute for Health and Care
Appraised Excellence (NICE) – 2016
guidelines for
 American College of Rheumatology – 2015
rheumatology
care  European League Against Rheumatism
(EULAR) 2020 recommendations
  Most common rheumatic disorder presenting
as inflammatory destruction of joints.
Rheumatoid
 Symmetrical, warm, swollen, painful joints
Arthritis
 May also be accompanied by systemic
involvement.
  Covers diagnosis and management of rheumatoid arthritis.
 Targeted for healthcare professionals, patients with RA and their
families and care providers.
NICE
Guidelines for AIMS

RA in adults  To improve quality of life by ensuring that people with rheumatoid

arthritis have the right treatment
 To slow the progression of their condition.
 To control the symptoms.
  Referral from primary care/ physician
 Investigations and Diagnosis
 Aims of treatment
 Treat-to-target strategy
Areas covered  Communication and education
by NICE  Pharmacological management
guideline
 Multidisciplinary team
 Non-pharmacological management
 Monitoring
 Timing and referral for surgery
  Any adult with suspected, persistent synovitis
of undetermined cause

 Small joints of hands and feet are affected

Referral
 More than 1 joint is affected.

 Delay of 3 or more months between onset of

symptoms and seeking medical advice
  Blood test for rheumatoid factor in adults with
suspected rheumatoid arthritis (RA) who are found to
have synovitis on clinical examination.
Investigations
 anti-CCP antibodies in adults with suspected RA if they
(for diagnosis)
are negative for rheumatoid factor.

 X-ray the hands and feet in adults with suspected RA

and persistent synovitis.

anti-CCP: anti-cyclic citrullinated peptide

  Anti-CCP bodies unless already measured for
confirmation
Investigations
(after  X-rays of hands and feet for erosions
diagnosis)
 Measurement of functional ability (Health
Assessment Questionnaire)
 AIM

 Achievement of a target of remission or low disease activity if

remission cannot be achieved (treat-to-target)
Treatment
(Treat-to-
target  In people with increased risk of radiological progression (presence of

strategy) anti-CCP or erosions on X-ray), target should be made remission

rather than low disease activity.

 Evidence showed that a treat-to-target strategy was more effective

than usual care for managing RA and improved outcomes at no
additional cost.
  The treat-to-target approach was more likely to
achieve rapid and sustained disease control.
Treatment
(Treat-to-
target  For active RA, measurement of C-reactive protein
strategy)
(CRP) and disease activity (using DAS28) monthly until
one of the targets is achieved.
  Explain the risks and benefits of treatment
options.

 Offer opportunities to talk about and agree all

Communication aspects of care, and respect the decisions
and Education made.

 Improve their understanding of the condition

and its management and counter any
misconceptions.
 Initially, the first line of treatment drugs are

 the conventional disease-modifying anti-

rheumatic drugs (cDMARDs)
Pharmacological
management followed by additional management with

 Biological and targeted synthetic DMARDs,

 Glucocorticoids

 NSAIDS
  For newly diagnosed active RA, cDMARD
monotherapy (oral methotrexate, leflunomide
or sulfasalazine ASAP or ideally within 3
Pharmacological months of persistent symptoms.
management
 Alternatively, for mild/palindromic disease,
consider hydroxychloroquine.

 Short-term bridging treatment with

glucocorticoids on starting a new cDMARD.
  Patients with active arthritis may benefit from anti-
inflammatory effects of glucocorticoids.

Pharmacological  Additional cDMARDs should be offered in a step-up

management strategy when the target has not been achieved

 Additional DMARDs are added to cDMARD

monotherapy when disease is not adequately
controlled.
 Recommendations regarding the use of biological and
targeted synthetic DMARDs

Pharmacological  Use of IL-1 receptor antagonist (anakinra) is not

management recommended.

 Use of TNF-alpha inhibitors (rituximab) if symptoms

do not respond to cDMARDs.

 Combination of these drugs should not be offered

  Glucocorticoids should be offered short-term only for
managing flares in adults with recent onset or
established disease to rapidly decrease inflammation.

Pharmacological
management Symptoms control is achieved by:

 NSAIDs for pain and stiffness.

 Lowest effective dose for shortest possible time.

 With a proton-pump inhibitor (PPI)

 Access to a multidisciplinary team provides:

 Periodic assessment of disease effect on their

Multidisciplinary lives (pain, fatigue, everyday activities,
team mobility, quality of life, social participation,
mood, sexual relationships)

 Necessary help to manage the conditions.

 PHYSIOTHERAPY

 Improve general fitness and encourage regular exercise

 Learn exercises for enhancing joint flexibility, muscle

strength and managing other functional impairments
Non-  Learn about the short-term pain relief provided by methods
pharmacological such as transcutaneous electrical nerve stimulators (TENS)
management and wax baths.

OCCUPATIONAL THERAPY

Only if they have difficulties with everyday activities or hand

function.
 HAND EXERCISE PROGRAMMES

 Individually tailored strengthening and stretching hand

exercise programme for those with pain and dysfunction of

Non- hands or wrists

pharmacological  If they are not on a drug regimen for RA

 If they have been on a stable regimen for at least 3 months.

management
PODIATRY

 For periodic review of foot health needs.

 Availability of functional insoles and therapeutic footwear.

 PSYCHOLOGICAL INTERVENTIONS

Non- Depression is common in adults living with a chronic physical health

problem.
pharmacological  Relaxation
management  Stress management
 Cognitive coping skills
 DIET AND COMPLEMENTARY THERAPIES

 Mediterranean diet is encouraged (more bread, fruit,

vegetables and fish; less meat).

Non-  Replace butter and cheese with products based on

pharmacological vegetable and plant oils.
management  Inform adults with RA who wish to try complementary
therapies that although some may provide short-term
symptomatic benefit, there is little or no evidence for
their long-term efficacy
  Review appointment every 6 months.
 Assess disease activity and damage and measure functional ability
(using Health Assessment Questionnaire (HAQ)).
 Assess comorbidities such as hypertension, ischemic heart
Monitoring diseases, osteoporosis and depression
 Assess symptoms of complications such as vasculitis, disease of
cervical spine (myelopathy), lung or eyes
 Do not use ultrasound for routine monitoring of disease activity
 For adults who have maintained treatment target for at least 1
year, drug doses can be cautiously reduced or stopped in a step-
down strategy.
  persistent pain due to joint damage or other identifiable soft
tissue cause
 worsening joint function
Timing and  progressive deformity persistent
referral for  localized synovitis
surgery  imminent or actual tendon rupture
 nerve compression (for example, carpal tunnel syndrome)
 stress fracture.
 Alison Hammond and Yeliz Prior (2016) conducted a systematic review on the
effect of home hand exercises in RA.

 Collected studies from Medline (1946-), AMED, CINAHL, Physiotherapy

Evidence Database, OT Seeker, the Cochrane Library, ISI Web of Science from
inception to January 2016.

Literature  Methodological quality was checked with PEDro scale.

review  Studies included resistance and ROM exercises for the fingers and wrist.

 Improvements in self-reported hand function, pain, self-efficacy grip strength

and ROM.

 Home hand exercise regimens should include at least four and up to six light
progressing to medium resistance hand exercises using therapeutic putty and
resistance bands performed at high intensity (i.e. 10 repetitions of each
exercise most days/daily)
 George S Metsios, George D Kitas et. al (2015) in an expert review,
highlighted the effects of exercise on inflammation, cardiovascular
risk and psychological health in patients with RA.

 Physical activity levels are alarmingly low in patients with RA.

Literature
 Increased physical activity has protective cardiovascular effects
review
 Exercise significantly improves inflammation along with disease
related outcomes and psychological health.

 Aerobic and strengthening exercises do not exacerbate symptoms

 Exercises should be tailored to patient’s functional and

cardiopulmonary fitness levels.
  Maria EC Sandberg, Sara Wedren et. al (2014) presented report
on effect of physical activity on clinical presentation of RA.

 Used cases from Swedish Rheumatology Quality Register with

calculations of DAS28 score, VAS for pain and HAQ for activity
Literature limitations.at diagnosis.

review  Regular physical activity was associated with reduced scores of

DAS28 and VAS but not for HAQ.

 Physically active individuals seem to present with milder

symptoms .

 This adds to the evidence of beneficial effects of physical activity

on inflammatory diseases.