Rheumatoid arthritis – a clinical update for practice nurses

RHEUMATOID ARTHRITIS

DEFINITION

Rheumatoid arthritis (RA) is a chronic systemic inflammatory disease. RA presents as inflammatory arthritis typically affecting the small joints of the hands and the feet, 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.^1,2

The prevalence of confirmed RA is about 1% of the UK population. It is the most common inflammatory arthritis. RA onset can occur at any age, but it peaks between people aged 30–50 years. It is 2-4 times more common in women.^1-4

COMPLICATIONS

Complications of RA include weight loss, amyloidosis, anaemia, dry eye syndrome, fatigue, interstitial lung disease, vasculitis, ulcers, and peripheral neuropathy.

Orthopaedic problems are also common and include carpal tunnel syndrome, tendon rupture, cervical myelopathy, and a higher rate of joint replacement surgery.

Severe RA disease is also associated with comorbidities, including cardiovascular disease. Accelerated atherosclerosis is the leading cause of death in people with RA. Other complications include depression, serious infections, and lymphomas where the risk is double in people with RA.

Complications associated with drug treatment include gastrointestinal problems mainly due to the adverse effects of non-steroidal anti-inflammatory drugs, liver toxicity (for people taking methotrexate) , malignancy particularly TNF-alpha inhibitor-related (who have an increased risk of skin cancer), osteoporosis from low-dose glucocorticoid, and an increased risk of fractures and serious infections due to immunosuppression.^1-3

DIAGNOSIS

Practice nurses should suspect RA in anyone with persistent synovitis where there is no other obvious cause. You should use your clinical judgement to decide if the synovitis is 'persistent' (lasting a few weeks rather than days). Clinical features of synovitis include pain, swelling, heat, and stiffness in affected joints. Stiffness in the early morning usually lasts over an hour.^2,5

Persistent synovitis, and a poorer prognosis, are more likely when there are a greater number of joints affected (the more joints the worse the prognosis), there is swelling and tenderness in the affected joints (particularly small joints), the proximal finger joints are affected, and where there is a symmetrical pattern of joints affected. An inability to make a fist or flex fingers is associated with a higher likelihood of a diagnosis of RA.^2,5

In addition to joint synovitis, RA may present with rheumatoid nodules which are hard or firm swellings over extensor surfaces, or other features such as vasculitis, or systemic symptoms such as malaise, fatigue, fever, sweats, and weight loss.

The presentation of RA is variable. Most people have an insidious onset, but others can have a rapid, or relapsing and remitting course.^2,5

Differential diagnosis

Other conditions that can cause synovitis include connective tissue disorders, fibromyalgia, infectious arthritis, osteoarthritis, gout, polymyalgia rheumatica, psoriatic arthritis, reactive arthritis, septic arthritis, and sero-negative arthritis.^4,6,7

To exclude these diagnoses you may consider further investigations. However, you should be aware that there is no specific diagnostic test for RA, as the diagnosis is clinical. You should refer all people suspected of having RA for specialist assessment. If RA is suspected clinically, investigations are not necessary in primary care, however, practice nurses should consider some tests which might speed up the diagnostic process.^1-4

Tests which can be of benefit include rheumatoid factor (which is present in 60–70% of people with RA), anti-cyclic citrullinated peptide (anti-CCP) antibodies in people if they are negative for rheumatoid factor (which is present in about 80% of people with RA), and an X-ray of the hands and feet.^3,4

Other tests which may be helpful in defining a baseline and excluding other diagnoses include a full blood count, renal and liver function tests, C-reactive protein, and erythrocyte sedimentation rate (be aware that these may be raised but up to 40% of people with RA have normal levels of these inflammatory markers).

Is however important for practice nurses to recognise that investigations should not delay a referral for clinically suspected RA.^1,2

MANAGEMENT

Primary care

It is important that you refer people with persistent synovitis with an unknown cause to a rheumatologist for an appointment (within 3 weeks of referral) for specialist assessment.

You should refer urgently, within 3 working days of presentation 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 the onset of symptoms and the person seeking medical advice.

Whilst the person is waiting to be seen by a specialist you should consider offering a non-steroidal anti-inflammatory drug (NSAID) at the lowest effective dose for the shortest possible time for example, a standard NSAID such as ibuprofen, naproxen, or diclofenac, or a coxib (such as celecoxib or etoricoxib). If an NSAID is prescribed, you should also offer a proton pump inhibitor.

Do not prescribe a glucocorticoid before a specialist assessment is carried out as glucocorticoids may mask key clinical features of rheumatoid arthritis and delay the diagnosis.^2,3

Secondary care

In specialist rheumatology clinics a treat to target strategy is used with the aim of achieving a target of remission or low disease activity if remission cannot be achieved.^2,9

Specialists will usually offer a conventional disease modifying anti-rheumatic drug (cDMARD) for example, oral methotrexate, leflunomide, or sulfasalazine. The dose is increased depending on tolerance until the treatment target is achieved. Short-term bridging treatment with glucocorticoids may be used when starting a new cDMARD to improve symptoms while waiting for the new DMARD to take effect (which can take 2–3 months). Additional cDMARDs may be offered in combination in a step-up strategy when the treatment target (remission or low disease activity) has not been achieved despite dose escalation. Once the treatment target has been achieved drug doses may be stepped down or stopped.^2,9

If the disease is severe and has not responded to intensive therapy with a combination of cDMARDs, biological DMARDs may be offered in combination with methotrexate, or alone for people who cannot take methotrexate because it is contraindicated or because of intolerance.^2,9

DRUG MONITORING AND FOLLOW-UP

DMARDs require regular monitoring with blood tests. This may be done in secondary care but can be carried out in primary care under a shared care protocol. People starting a new disease-modifying antirheumatic drug should follow recommended blood monitoring guidelines.² In consultation with their specialist, each person may be able to safely increase the time interval between blood tests for drug monitoring, particularly if 3 monthly blood tests have been stable for more than 2 years.

The role of primary care as part of the multidisciplinary team managing people with RA is to ensure that all adults with RA have rapid access to specialist care for flares and information about when and how to access specialist care. For example, check the person:

• Has a named rheumatology specialist nurse who coordinates care
• Has access to physiotherapy, occupational therapy, and podiatry services for advice on mobility, pain control, work-related issues, and foot health.²

Practice nurses should also ensure all people with RA are offered an annual review, assess their disease activity, and measure functional ability (using, for example, the Health Assessment Questionnaire) check for the development of comorbidities, such as hypertension, ischaemic heart disease, osteoporosis, depression, or other complications, liaise with the person's specialist team, particularly in relation to changes in medication, and offer pneumococcal and yearly influenza vaccinations.2

Inform adults with RA who wish to experiment with their diet that there is no strong evidence that their arthritis will benefit. However, advise them about the benefits of a Mediterranean diet (plenty of fruit, vegetables, and fish; and less meat and butter), stopping smoking, and drinking only sensible amounts of alcohol, to reduce the risk of cardiovascular disease.²

Advise the person that although some complementary therapies may provide short-term symptomatic benefit, there is little or no evidence for their long-term efficacy in RA. If complementary therapy is being considered, explain that it should not replace prescribed medical treatment.²

MANAGING RHEUMATOID ARTHRITIS FLARES

Practice nurses faced with a person who has a flare-up in their RA symptoms should firstly exclude the possibility of septic arthritis (you should suspect this if a single joint is hot and swollen, especially if there are signs of sepsis).²

Once this has been excluded, you should suspect that this is instead a flare of RA if there are worsening symptoms of stiffness, pain, joint swelling, or general fatigue, signs of joint synovitis, joint tenderness, or loss of joint function and raised levels of inflammatory markers, for example an increase in C-reactive protein or ESR from previous levels.^2,5,9 If you are dealing with a person who you suspect is suffering a RA flare you should seek specialist advice about their management.²

Additionally you should work with your colleagues at the practice to offer short-term treatment with glucocorticoids, either an intra-articular glucocorticoid injection for a localised RA flare, if the expertise is available in primary care, or an intramuscular glucocorticoid if an intra-articular glucocorticoid is not possible or appropriate.^2,5,9

An oral glucocorticoid can also be considered using a reducing course of an oral glucocorticoid over 2-4 weeks. This can be started while awaiting specialist assessment. The dosing regimen for a 2-week course would be prednisolone 10 mg daily for 7 days, then 5 mg daily for 7 days, then stop.²

A NOTE ON RA AND COVID-19 INFECTION

Be aware that people having immunosuppressant treatments may have atypical presentations of COVID-19. For example, people taking prednisolone may not develop a fever, and those taking interleukin 6 inhibitors may not develop a rise in C reactive protein. It is, however, vitally important that people with rheumatoid disease suspected to have, or with known, COVID-19, should continue their therapy unless advised to do otherwise by the specialist monitoring their condition.¹⁰

Clearly people in this higher risk group should be vaccinated against COVID-19. As their response to vaccines may be attenuated it is recommended that they have three vaccine doses, then a fourth as a booster.¹¹

People on immunosuppressants who test positive for COVID-19 should also be advised to access treatment with Paxlovid (nermatrelvir and ritonavir) as this medication is effective at reducing the risk of hospitalisation and death in people with mild to moderate COVID-19 infection and who are at an increased risk of developing severe disease.¹²

Conclusion

Rheumatoid arthritis is the most common inflammatory arthritis, affecting 1% of the UK population. In an average practice of 9,000 patients, you can therefore expect that 90 people will suffer rheumatoid arthritis. These people are more likely to have a need for interventions, review, and support than many other patients at the practice. Some will have mental as well as physical healthcare issues. Practice nurses may well be very familiar with their regular RA attendees and provide a key role in monitoring, management, and advocacy for these individuals. Thankfully, modern DMARD treatments have improved the condition and prognosis for these patients, but issues of immunosuppression and the potential complications (particularly with emerging infections) should remain uppermost in our minds when we interact with patients with rheumatoid disease.

References

1. SIGN. Management of early rheumatoid arthritis; 2011. https://www.sign.ac.uk/our-guidelines/management-of-early-rheumatoid-arthritis/

2. NICE. Pathway: Drug treatment for rheumatoid arthritis. Last updated November 2021. https://pathways.nice.org.uk/pathways/rheumatoid-arthritis/drug-treatment-for-rheumatoid-arthritis

3. Ledingham J, Snowden N, Ide Z. Diagnosis and early management of inflammatory arthritis. BMJ 2017;358:j3248

4. Wasserman AM. Diagnosis and management of rheumatoid arthritis. American Family Physician 2011;84(11), 1245-1252

5. NICE NG100. Rheumatoid arthritis in adults: management; 2018 (updated 2020). https://www.nice.org.uk/guidance/ng100

6. BMJ Best Practice. Rheumatoid arthritis; 2018 (Updated December 2021). https://bestpractice.bmj.com/topics/en-gb/105

7. Smolen JS, Aletaha D, McInnes IB. Rheumatoid arthritis. Lancet 2016;388, 2023-2038

8. American College of Rheumatology (ACR) 2021 Guideline for the treatment of rheumatoid arthritis. Arthritis Care Res 2021;73(7):924-939. https://www.rheumatology.org/Portals/0/Files/2021-ACR-Guideline-for-Treatment-Rheumatoid-Arthritis-Early-View.pdf

9. Canadian Rheumatology Association. Recommendations for pharmacological management of rheumatoid arthritis with traditional and biologic disease-modifying antirheumatic drugs. The Journal of Rheumatology 2012;39(8), 1559-1582.

10. NICE NG167. COVID-19 rapid guideline: rheumatological autoimmune, inflammatory, and metabolic bone disorders; 2020 (updated 2021). https://www.nice.org.uk/guidance/ng167

11. NICE Clinical Knowledge Summaries. Coronavirus – COVID-19; 2021 https://cks.nice.org.uk/topics/coronavirus-covid-19/

12. UK Government Oral COVID-19 antiviral, Paxlovid, approved by UK regulator; 31 December 2021 https://www.gov.uk/government/news/oral-covid-19-antiviral-paxlovid-approved-by-uk-regulator