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Rheumatoid Arthritis: National Clinical Guideline for Management and Treatment in Adults

Rheumatoid Arthritis: National Clinical Guideline for Management and Treatment in Adults

NICE Clinical Guidelines - National Collaborating Centre for Chronic Conditions (UK)

Version: February 2009

Pharmacological management

In previous decades, DMARDs were introduced when patients fulfilled the ARA classification criteria for RA, or when there were radiological erosions. It is now recognised that the ARA classification criteria are not designed to identify recent-onset RA (see section 4), and that persistent synovitis needs an appropriate disease modifying drug intervention irrespective of the distribution of joints affected, and the results of investigations. Consequently, the early introduction of DMARDs has been advocated for any persistent idiopathic synovitis. This decision is not always straightforward, because of diagnostic and prognostic difficulties, and also concerns over toxicity associated with DMARDs. There are also practical difficulties, with delays from symptom onset, to presentation to GP, to referral to secondary care, averaging 9 months in total in the UK. Irrespective of these diagnostic, prognostic and practical difficulties, a concept of a ‘window of opportunity’ has emerged in the RA literature, expressing the belief that the earlier the introduction of DMARDs, the greater the impact on long-term outcomes. Is there any evidence to support this?

Evidence Tables

The duration of symptoms was significantly shorter in patients referred to the EAC compared with the routine clinic (p<0.00001)

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