New Guidelines Focus on Prompt Management of Early Arthritis

The availability of more effective arthritis drugs and monitoring techniques has created a critical window of opportunity when joint destruction can be averted and function maintained. To help clinicians make the most of this crucial period in management of the disease, an expert committee of the European League Against Rheumatism has written new guidelines on optimal management of early arthritis.

Among the issues addressed by the guidelines are the need for accurate, prompt diagnosis and the early institution of disease-modifying antirheumatic drug (DMARD) therapy and, if appropriate, nonsteroidal anti-inflammatory agents and corticosteroids (Ann. Rheum. Dis. 2007;66:34–45). They also provide guidance on monitoring and nonpharmaceutic adjuncts to treatment, and set out an agenda for further research.

The recommendations, which are based on evidence in the literature as well as expert consensus, are as follows:

▸ Patients presenting with arthritis of more than one joint should be referred to a rheumatologist, if possible within 6 weeks of symptom onset.

▸ Clinical examination is the method of choice for diagnosis, although imaging studies with ultrasound and MRI can be helpful when there is uncertainty.

▸ A careful history is needed to rule out other diagnoses, along with laboratory tests including complete blood cell count, urinalysis, measurement of transaminases, and detection of antinuclear antibodies.

▸ All patients with early arthritis should be evaluated for factors that are predictive of persistent and erosive disease, including number of swollen and tender joints, erythrocyte sedimentation rate or C-reactive protein, rheumatoid factor, anticyclic citrullinated peptide antibodies, and radiographic erosions.

▸ Patients at risk for persistent or erosive disease should begin therapy with DMARDs even if their arthritis remains undifferentiated.

▸ Educational measures may be employed adjunctively to help patients deal with pain and disability.

▸ Nonsteroidal anti-inflammatory drugs can be considered for symptomatic relief, with consideration given to potential adverse gastrointestinal, renal, and cardiovascular effects.

▸ Systemic corticosteroids can be used in addition to DMARDs, generally in a temporary fashion, and intra-articular corticosteroid injections should be considered for local symptomatic inflammation.

▸ Methotrexate is considered the “anchor” DMARD, with leflunomide and sulfasalazine as alternatives when necessary.

▸ The goal of DMARD therapy is remission, and monitoring should guide treatment decisions and strategy changes as needed.

▸ Nonpharmaceutic interventions such as exercise can be helpful in improving strength and physical function in patients with early arthritis.

▸ Routine monitoring during early disease should include tender and swollen joint counts, patient and physician global assessment, and measurement of erythrocyte sedimentation rate and C-reactive protein, and structural damage should be monitored by x-rays every 6–12 months.

The availability of more effective arthritis drugs and monitoring techniques has created a critical window of opportunity when joint destruction can be averted and function maintained. To help clinicians make the most of this crucial period in management of the disease, an expert committee of the European League Against Rheumatism has written new guidelines on optimal management of early arthritis.

Among the issues addressed by the guidelines are the need for accurate, prompt diagnosis and the early institution of disease-modifying antirheumatic drug (DMARD) therapy and, if appropriate, nonsteroidal anti-inflammatory agents and corticosteroids (Ann. Rheum. Dis. 2007;66:34–45). They also provide guidance on monitoring and nonpharmaceutic adjuncts to treatment, and set out an agenda for further research.

The recommendations, which are based on evidence in the literature as well as expert consensus, are as follows:

▸ Patients presenting with arthritis of more than one joint should be referred to a rheumatologist, if possible within 6 weeks of symptom onset.

▸ Clinical examination is the method of choice for diagnosis, although imaging studies with ultrasound and MRI can be helpful when there is uncertainty.

▸ A careful history is needed to rule out other diagnoses, along with laboratory tests including complete blood cell count, urinalysis, measurement of transaminases, and detection of antinuclear antibodies.

▸ All patients with early arthritis should be evaluated for factors that are predictive of persistent and erosive disease, including number of swollen and tender joints, erythrocyte sedimentation rate or C-reactive protein, rheumatoid factor, anticyclic citrullinated peptide antibodies, and radiographic erosions.

▸ Patients at risk for persistent or erosive disease should begin therapy with DMARDs even if their arthritis remains undifferentiated.

▸ Educational measures may be employed adjunctively to help patients deal with pain and disability.

▸ Nonsteroidal anti-inflammatory drugs can be considered for symptomatic relief, with consideration given to potential adverse gastrointestinal, renal, and cardiovascular effects.

▸ Systemic corticosteroids can be used in addition to DMARDs, generally in a temporary fashion, and intra-articular corticosteroid injections should be considered for local symptomatic inflammation.

▸ Methotrexate is considered the “anchor” DMARD, with leflunomide and sulfasalazine as alternatives when necessary.

▸ The goal of DMARD therapy is remission, and monitoring should guide treatment decisions and strategy changes as needed.

▸ Nonpharmaceutic interventions such as exercise can be helpful in improving strength and physical function in patients with early arthritis.

▸ Routine monitoring during early disease should include tender and swollen joint counts, patient and physician global assessment, and measurement of erythrocyte sedimentation rate and C-reactive protein, and structural damage should be monitored by x-rays every 6–12 months.

The availability of more effective arthritis drugs and monitoring techniques has created a critical window of opportunity when joint destruction can be averted and function maintained. To help clinicians make the most of this crucial period in management of the disease, an expert committee of the European League Against Rheumatism has written new guidelines on optimal management of early arthritis.

Among the issues addressed by the guidelines are the need for accurate, prompt diagnosis and the early institution of disease-modifying antirheumatic drug (DMARD) therapy and, if appropriate, nonsteroidal anti-inflammatory agents and corticosteroids (Ann. Rheum. Dis. 2007;66:34–45). They also provide guidance on monitoring and nonpharmaceutic adjuncts to treatment, and set out an agenda for further research.

The recommendations, which are based on evidence in the literature as well as expert consensus, are as follows:

▸ Patients presenting with arthritis of more than one joint should be referred to a rheumatologist, if possible within 6 weeks of symptom onset.

▸ Clinical examination is the method of choice for diagnosis, although imaging studies with ultrasound and MRI can be helpful when there is uncertainty.

▸ A careful history is needed to rule out other diagnoses, along with laboratory tests including complete blood cell count, urinalysis, measurement of transaminases, and detection of antinuclear antibodies.

▸ All patients with early arthritis should be evaluated for factors that are predictive of persistent and erosive disease, including number of swollen and tender joints, erythrocyte sedimentation rate or C-reactive protein, rheumatoid factor, anticyclic citrullinated peptide antibodies, and radiographic erosions.

▸ Patients at risk for persistent or erosive disease should begin therapy with DMARDs even if their arthritis remains undifferentiated.

▸ Educational measures may be employed adjunctively to help patients deal with pain and disability.

▸ Nonsteroidal anti-inflammatory drugs can be considered for symptomatic relief, with consideration given to potential adverse gastrointestinal, renal, and cardiovascular effects.

▸ Systemic corticosteroids can be used in addition to DMARDs, generally in a temporary fashion, and intra-articular corticosteroid injections should be considered for local symptomatic inflammation.

▸ Methotrexate is considered the “anchor” DMARD, with leflunomide and sulfasalazine as alternatives when necessary.

▸ The goal of DMARD therapy is remission, and monitoring should guide treatment decisions and strategy changes as needed.

▸ Nonpharmaceutic interventions such as exercise can be helpful in improving strength and physical function in patients with early arthritis.

▸ Routine monitoring during early disease should include tender and swollen joint counts, patient and physician global assessment, and measurement of erythrocyte sedimentation rate and C-reactive protein, and structural damage should be monitored by x-rays every 6–12 months.