Definitions for the level of evidence (1-5) and the grades of recommendations (A-D) are sourced or provided at the end of the "Major Recommendations."
Diagnosis
Suspected Rheumatoid Arthritis (RA)
Importance of Early Diagnosis in RA
- The sooner RA treatment begins, the higher the likelihood of controlling the inflammatory process and reducing structural damage; thus, "recent-onset arthritis" should be considered a diagnostic priority. [1.a, A]
Detection of RA in Primary Care
- The longest a patient with suspected RA should wait for a rheumatology appointment is 2 weeks. [5, D]
Criteria for Referral to from Primary Care to Rheumatology
- All cases of arthritis lasting more than 4 weeks should be referred to specialty care, regardless of the suspected diagnosis. Patients with suspected septic arthritis should be referred immediately. [5, D]
Table: Criteria for Referral of Recent-Onset Arthritis to Specialty Care
Criteria for arthritis referral from the SERAP* project
Presence during > 4 weeks of: |
|
1. Swelling in two or more joints, as evidenced by the squeeze test (lateral compression of metacarpophalangeal or metatarsophalangeal joints) |
| 2. Involvement of metacarpophalangeal or metatarsophalangeal joints |
| 3. Morning stiffness lasting more than 30 minutes |
| Specific RA referral criteria according to Emery |
| 1. Swelling in three or more joints |
| 2. Pain on palpating metacarpophalangeal or metatarsophalangeal joints |
| 3. Morning stiffness lasting more than 30 minutes |
*The SERAP project was launched in November 2004 by the SER in 36 reference hospitals with rheumatology departments.
How to Improve Referral from Primary Care to Rheumatology Care
- The diagnostic yield from primary care can be improved if patients are discussed previously with the specialty unit or reference rheumatologist and/or with joint development of protocols defining the criteria for referral. [5, D]
Organization of the Consult in Its Interaction with Primary Care
- Training measures and protocols should be agreed with primary care physicians, with good communication between the two levels (primary and specialty care); this makes it possible to evaluate the effectiveness of the protocols, be reminded of the importance of using them, and demonstrate their utility. [5, D]
1987 American College of Rheumatology (ACR) Classification Criteria
The 1987 ACR criteria in list form, perform well in patients with established disease. RA is considered to be probable when 4 or more of the 7 criteria in the list are present.
The 1987 ACR classification criteria are currently widely used as the gold standard for RA diagnosis.
The 1987 ACR criteria perform more poorly in disease of recent onset. In this stage the clinical criteria (1 to 4) are sensitive but not very specific for RA, while the remaining criteria are specific but not very sensitive.
Table: ACR Classification Criteria for Rheumatoid Arthritis (1987)
| 1. Morning stiffness |
Morning joint stiffness lasting at least 1 hour. |
| 2. Arthritis of 3 or more joint areas |
Simultaneous inflammation of at least 3 joint areas, as observed by a physician. The 14 joint areas are: proximal interphalanges, metacarpophalanges, wrists, elbows, knees, ankles and metatarsophalanges. |
| 3. Arthritis of hand joints |
Inflammation of at least one hand area (carpal, metacarpophalangeal, proximal interphalangeal). |
| 4. Symmetrical arthritis |
Simultaneous involvement of the same joint areas (as defined in criterion 2) on both sides of the body. |
| 5. Rheumatoid nodules |
Subcutaneous nodules over bony prominences, extensor surfaces or in juxta-articular regions, observed by a physician. |
| 6. Serum rheumatoid factor |
Demonstration of elevated amounts of serum rheumatoid factor by any method for which the result has been positive in less than 5% of control subjects. |
| 7. Radiologic changes |
Radiologic changes typical of rheumatoid arthritis on posteroanterior hand radiographs. Must include erosions or unequivocal juxta-articular osteoporosis in involved joints. |
Diagnostic Utility of Biological Tests in Recent-Onset RA
Anti-Cyclic Citrullinated Peptide Antibody (Anti-CCP)
- Anti-CCP determination should be requested when evaluating a patient with recent-onset arthritis. [1b, A]
Evaluation
Specific RA Evaluation
Appropriate Data for First Evaluation of RA Patient
- The first evaluation of an RA patient should include: clinical history, physical examination, blood test and urinalysis. [5, D]
Clinical History
- The clinical history should include: family and personal history, sociodemographic data, previous history of current disease and treatments (previous and concomitant). [5, D]
Physical Examination
- The physical examination, in addition to the routine exam of organs and systems, should include a detailed evaluation of the musculoskeletal system. [5, D]
Blood Test and Urinalysis
- The blood test should include: complete blood count, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), rheumatoid factor (RF), anti-CCP, liver biochemistry and serology, and renal function. For urine, a basic urinalysis is sufficient. [5, D]
Data Common to the Initial Evaluation and Follow-up of RA
- Both the initial and follow-up RA evaluations should be based on the systematic assessment of a minimum set of parameters which allow evaluation of the degree of inflammatory activity, functional disability and residual structural damage. The use of specific forms to facilitate systematic data collection is recommended. [5, D]
Table. Minimum Set of Parameters for RA Evaluation Recommended by OMERACT 1993 (Outcome Measures in Rheumatoid Arthritis Clinical Trials)
| 1. Number of painful joints |
| 2. Number of swollen joints |
| 3. Pain |
| 4. Global disease assessment by the patient |
| 5. Global disease assessment by the physician |
| 6. Acute phase reactants |
| 7. Physical functional capacity |
| 8. Radiologic damage (RA of more than 1 year's evolution)* |
*The evaluation of radiographic damage is recommended for studies lasting 1 year or more, although the results of more recent studies have shown that radiographic changes in the hands and feet can be observed in periods of as little as 6 months.
Parameters to Measure the Degree of Inflammatory Activity
- Evaluation of inflammatory activity is recommended by counting the number of painful and swollen joints, assessment of pain, global disease assessment (by patient and by physician), measurement of acute phase reactants and synthesis of this information using combined activity indices (Disease Activity Score [DAS], Simplified Disease Activity Index [SDAI]). [5, D]
Joint Counts
- The evaluation of the number of painful joint and the number of swollen joints should be performed using validated methods based on counting at least 28 joints. [5, D]
Evaluation of Pain
- Pain should be assessed by the patient him/herself. It is recommended that pain be measured using a horizontal visual analog scale, 10 cm in length, divided by vertical marks into ten equal 1-cm segments. The measurements should be accompanied by numeric descriptors from 0 to 10, with indicators at each end showing no pain (0) and worst pain (10). (see Figure 1 in the original guideline document). [5, D]
Global Assessment of Disease
- A global assessment of disease should be made, from the point of view of both the physician and the patient. For this measurement, the use of a 10 cm horizontal visual analog scale is recommended, with vertical marks dividing it into 10 equal 1 cm segments. The measurements should be accompanied by numeric descriptors from 0 to 10, with "very good" (0) at one end and "very poor" (10) at the other. (see Figures 2 and 3 in the original guideline document). [5, D]
Acute Phase Reactants
- Laboratory tests should include two acute phase reactants (APRs): erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). The behavior of these two APRs is closely related with the inflammatory activity of the disease. [5, D]
Composite Indices of Disease (DAS, SDAI)
The use of composite indices summarizing information on various parameters in a single indicator is a useful and valid procedure in assessing disease activity. This guideline recommend the use of the Disease Activity Score (DAS/DAS28) and/or the SDAI (Simplified Disease Activity Index). [5, D]
Classification of Level of Inflammatory Activity
The ACR considers clinical remission to exist when at least 5 of the 6 criteria are met for a period of at least 2 months. The clinical utility of this definition is low because it uses 2 criteria not routinely used in patient evaluation.
Table: ACR Criteria* for Clinical Remission of RA
| 1. Morning stiffness absent or not exceeding 15 minutes |
| 2. No fatigue |
| 3. No joint pain in medical history |
| 4. No joint tenderness |
| 5. No soft tissue swelling in joints or tendon sheaths |
| 6. Normal erythrocyte sedimentation rate |
* ACR considers clinical remission to occur when at least 5 of the 6 criteria are met.
Evaluation of Disability
Physical Disability
- Self-perceived functional disability attributed to the disease should be evaluated with specific, previously validated questionnaires. This guideline recommends the use of the Health Assessment Questionnaire (HAQ) as a tool for the standard evaluation of disability, due to its wide diffusion, acceptance and proven metric characteristics. [5, D]
Ability to Work
- RA very frequently causes loss of the ability to work. The panel recommends that this aspect be jointly assessed with the patient to implement strategies that make it possible to continue working as long as possible without prejudice to the patient. [5, D]
Psychological and Social Aspects
- Some psychological aspects such as mood (depression, anxiety) or social support are very important for patients and can affect compliance with treatment and treatment response. The panel recommends keeping these aspects in mind when assessing the need for additional interventions. [5, D]
Evaluation of Structural Damage
Radiologic Indices
- Radiographs of the hands, feet and chest are recommended in the initial evaluation; hand and foot radiographs should be repeated annually during the first three years of disease evolution and subsequently as deemed necessary. [5, D]
Ultrasonography
- Ultrasound is recommended when the physical examination raises doubts about the existence of signs of inflammatory joints, or when ultrasound detection of synovitis, effusion, or erosions will modify management of the patient's treatment. [5, D]
Magnetic Resonance Imaging (MRI)
- MRI is recommended for the detection of synovitis, effusion and erosions when this information is considered to be clinically relevant. [5, D]
Evaluation of Prognosis
- The initial and subsequent evaluation of RA patients should include a continuing estimate of disease prognosis. The evaluation of prognosis should take into account sociodemographic factors, genetic markers, disease-dependent factors, treatment-dependent factors, and psychological and social factors. [5, D]
Treatment Evaluation
Objective of RA Treatment
- The objective of RA treatment is to induce complete remission of the disease or, alternatively, to achieve the least possible inflammatory activity (LPIA). [5, D]
Treatment-Response Criteria
- Treatment-response criteria should be applied to each patient individually; therefore, they should take into account the change in disease activity and the current degree of activity. [5, D]
ACR Response Criteria
- The ACR criteria do not take current disease status into account, therefore the following modification proposed by the SER is recommended if they are applied. [5,D]
The ACR criteria for improvement define a dichotomous outcome (response/no response) according to the following criteria:
- Improvement of 20% or more in the tender joint count and in the swollen joint counts.
- Improvement of 20% or more in at least 3 of the following parameters: ESR or CRP, physician global assessment of disease activity, patient global assessment of disease activity, patient pain assessment, physical disability.
The ACR response criteria are likely to be modified in the near future; meanwhile, the following adaptation is proposed: (http://www.ser.es/):
- Satisfactory response: fulfillment of the ACR20 criteria, fewer than 6 swollen joints, and absence of any patient circumstance that results in intolerable loss of functional capacity in the opinion of the patient or physician.
- Unsatisfactory response: failure to meet the criteria for satisfactory response.
Subjective Physician Assessment of Disease Activity
- The subjective physician assessment of disease activity is the clinical criterion most commonly used in daily practice. It is not advisable to use it as the only response criterion. [5, D]
Frequency of Check-ups
- RA patients should be followed indefinitely: cases of established RA and in complete disease remission should be evaluated every 6-12 months; those with frequent outbreaks or with persistent activity and those who have recent-onset disease should be assessed "on demand" (in general, every 1-3 months) until remission is achieved or until reaching and maintaining the least possible inflammatory activity. [5, D]
Nursing Consultations
- The active incorporation of nursing staff is recommended from the outset to assist in the evaluation of disease inflammatory activity, facilitate early detection of side effects and comorbidity, and improve health education. [5, D]
Periodic Check-ups and Administration of Questionnaires
- Joint counts and other parameters included in the systematic clinical evaluation of the patient should be carried out in the nursing consultation. [5, D]
Monitoring the Adverse Effects of Disease-Modifying Anti-rheumatic Drugs (DMARDs) and Treatment with Biologics
- It is recommended that adverse treatment effects be monitored in the nursing consultation. The rheumatologist who is responsible for the patient should be informed of any possible adverse effect, whether objective or subjective. [5, D]
Patient Education
- A patient education program should be implemented that includes at least the following aspects: 1) monitoring and control of the adverse effects of DMARDS and biologic treatments; 2) exercise; 3) pain control; 4) joint protection. [5, D]
RA Comorbidity
- The rheumatologist is responsible for controlling the inflammatory process and should monitor RA-associated comorbidity with the support of the primary care physician and with recourse to other specialists when needed. [5, D]
RA Complications
Amyloidosis
- Secondary amyloidosis should be suspected in RA patients who develop proteinuria, renal failure, gastrointestinal symptoms, myocardiopathy and/or hepatomegaly, and in those who have elevated acute phase reactants (APR) concurrent with little clinical activity. [5, D]
- Treatment should be preventive and should aim to suppress the inflammatory activity of RA. There is no single clear standard for the treatment of established amyloidosis. Several published case series have shown important improvements in proteinuria and renal function in patients with amyloidosis secondary to RA treated with anti-tumor necrosis factor (anti-TNF), which, given its lower toxicity, is a good treatment alternative. [4, C]
Anemia
- Periodic blood cell counts and general liver and kidney function tests are recommended. [5, D]
- Chronic anemia in conjunction with RA does not usually require treatment. Oral iron supplements are not indicated, except in cases of ferropenic anemia. The use of erythropoietin is controversial. [5, D]
Cardiological Complications
- RA-related cardiac involvement should be suspected in the presence of pericardial pain, heart failure or conduction abnormalities. [5, D]
- Pericarditis should be treated initially with full doses of nonsteroidal anti-inflammatory drugs (NSAIDs) (150 mg/day of indomethacin); if this is not effective, prednisone (1mg/kg/day); the rare cases of cardiac tamponade should be treated with evacuation by pericardiocentesis. [4, C]
- In addition to treatment for heart failure, myocarditis requires treatment with high-dose prednisone. [4, C]
Pulmonary Complications
- Pulmonary disease should be suspected if there is pleuritic pain, progressive or recent-onset dyspnea, or hemoptysis. [5, D]
- In the case of pleural involvement, thoracocentesis is recommended to obtain an exudate and rule out other diseases (infection or neoplasia). [5, D]
- Pleural involvement should be treated with full-dose or medium-dose steroids (10-20 mg/day of prednisone). [4, C]
- Rheumatoid nodules do not require treatment in the absence of complications. [5, D]
- Recent-onset (acute) interstitial involvement is treated with prednisone (1-1.5 mg/kg/day). If there is no response, patients may be treated with cyclophosphamide or azathioprine. Bronchiolitis obliterans organizing pneumonia (BOOP) is treated with prednisone (1.5 mg/kg/day). [4, C]
Felty's Syndrome
- Treatment for Felty's syndrome requires comprehensive control of RA inflammatory activity. As a specific measure, the use of filgrastim is recommended when the absolute neutrophil count is lower than 1,000/mm3 and the patient has a history of severe infections associated with the disease. [5, D]
Secondary Sjögren's Syndrome (SSS)
- There are no specific recommendations for modifying the course of SSS in RA. The recommendations in this guideline include symptomatic treatment of xerophthalmia and xerostomia. Dental and ophthalmological examinations at least every 6 months are recommended. [5, D]
Vasculitis
- Palpable purpura should be treated with full-dose NSAIDs and medium-low doses of prednisone (15-30 mg/day). [4, C]
- Polyarteritis nodosa is treated initially with high-dose steroids (40-120 mg/day of prednisone). If there is no response, cyclophosphamide should be added (2-3 mg/kg/day orally or 0.5-1 g/m2 in intravenous pulses of 2 to 4 weeks). [4, C]
Comorbidity Not Directly Related with RA
Infections
- Extreme precautions should be exercised in RA patients to prevent infections. Recommended measures include receipt of routine vaccinations, but never with attenuated microorganisms if the patient is receiving immunosuppressive treatment [4, C], avoiding contacts with tuberculosis patients and receiving chemoprophylaxis with isoniazid as needed [2.b, B], and practicing scrupulous dental hygiene. [2.b, B]
Tuberculosis
The following recommendations of the Spanish Society of Rheumatology and the Spanish Medicines Agency (AEME in Spanish) have made it possible to reduce the risk of tuberculosis (TB) activation in patients undergoing anti-tumor necrosis factor (anti-TNF) treatment to nearly normal levels:
Table: SER and AEME Recommendations to Control the Risk of TB in Patients with Anti-TNF Treatment
| Clinical history should include: |
History of tuberculosis |
| Recent contacts with tuberculosis patients |
| Should also perform: |
Chest radiograph to rule out active tuberculosis or radiographic signs consistent with old tuberculosis infection |
| Tuberculin skin test (PPD) (see following table) |
Table: SER and AEME Recommendations According to PPD Results
| If PPD is positive (induration ≥ 5 mm at 48-72 hours), patient is considered to have latent tuberculosis infection. |
| If anergy or induration less than 5 mm is detected, a new tuberculin test (booster) should be performed, 1-2 weeks afterwards, especially in persons over age 50. |
| If induration is ≥ 5 mm at 48-72 hours after booster, patient is also considered to have tuberculosis infection. |
| In individuals vaccinated with BCG it is impossible to know whether a positive PPD is a consequence of the vaccine or indicates latent tuberculosis infection; therefore, the same recommendations should be followed as for those who are not vaccinated. |
Cardiovascular Complications
- Individual risk factors for cardiovascular (CV) complications should be identified and treated: age, male sex, highly active arthritis, smoking, arterial hypertension, hypercholesterolemia and history of CV episode. [1.b, A]
Osteoporosis
- When RA is first diagnosed, the principal risk factors for fracture and loss of bone mass should be analyzed; if any are present, bone densitometry is indicated. [5, D] (See Table 19 in the original guideline document).
- The first-line treatment options for osteoporosis are alendronate and risedronate, with cyclic etidronate or calcitonin as alternatives. [5, D]
- Hormone treatment is not indicated. [5, D]
Table: Risk Factors for Osteoporosis
| Factors Independent of RA |
| Age over 65 years |
| History of fragility fracture after age 40 |
| Body weight less than 58 kg |
| Fragility fractures in first-degree relatives |
| Smoking |
| Early menopause |
| Prolonged amenorrhea |
| Male hypogonadism |
| Other predisposing diseases for osteoporosis |
| Factors Associated with RA or Its Treatment |
| Active disease |
| HAQ >1.25 |
| Treatment with glucocorticoids: >7.5 mg/d for more than 3 months, continuous treatment with >2.5 mg/d, or cumulative dose over 30 g. |
Neoplasias
- Discontinuation of all tobacco use is indicated in all RA patients. [5, D]
- Anti-TNFs are not recommended in patients with a personal history of lymphoma. [4, C]
- In patients with a personal history of lymphoma, the risk/benefit ratio should be carefully evaluated before deciding to use a TNF antagonist. [5, D]
- History of a malignant solid tumor in the last 5 years is a contraindication for the use of nti-TNF agents. [5, D]
- If there is history of a malignant solid tumor longer than 5 years previously, the physician should consult the specialist in oncology about the biopathology of the tumor. [5, D]
- An RA patient who develops a tumor should discontinue all DMARDs except antimalarials, gold salts, and sulfasalazine. [5, D]
Pharmacological Treatment
Pharmacological Treatment of Recent-Onset Rheumatoid Arthritis
- All RA patients should be treated with a DMARD as soon as the clinical diagnosis of the disease is established, regardless of whether they meet the ACR classification criteria. [5, D]
- The initial treatment recommended in all patients who have not been previously treated with a DMARD is methotrexate (MTX), due to its excellent safety and efficacy profile. [5, D]
- For optimal use of MTX as a remission-inducing agent in early RA, a rapid step-up dose to 20 or 25 mg weekly is recommended by 3-4 months after initiation of MTX. In refractory cases, MTX bioavailability should be assured by subcutaneous administration. [5, D]
- Nonetheless, given the clinical complexity of RA, the panel considers that, in some clinical situations, initial DMARD treatment may consist of using other drugs that have also been shown to control signs and symptoms of the disease and to delay radiologic progression. [5, D]
- In early RA with no markers of poor outcome (radiologic erosions, RF, anti-CCP antibodies, absence of extra-articular disease, HAQ over 1 or high inflammatory burden), it is acceptable to begin treatment with other DMARDs that have a lower toxicity profile or are easier to monitor for side effects; typical examples of these are the anti-malarials or sulfasalazine (SSZ). [5, D]
- In early RA that is expected to be especially incapacitating due to characteristics of the disease, the patient, or the patient's type of employment, initial combination therapy with MTX and an anti-TNF agent may be indicated; the objective of this treatment is to induce rapid remission and try to withdraw the anti-TNF agent and maintain RA remission with MTX in monotherapy. [5, D]
Refer to Table 21 in the original guideline document for recommended doses and commercial names of DMARDs.
Changes in Treatment
- Treatment failure or toxicity should be evaluated in a maximum of 3 months and a consequent change in treatment should be considered. The objective of treatment should be to maintain a Disease Activity Score using a count of 28 joints (DAS28) of <3.2. [5, D]
- If response to MTX is unsatisfactory after reaching the maximum dosage and assuring the bioavailability of the agent, the panel recommends the use of leflunomide (LEF) or SSZ or an anti-TNF agent as the second step in the treatment ladder, either replacing or in addition to MTX. If MTX toxicity is such as to oblige its withdrawal, the panel recommends using LEF or SSZ or an ant-TNF agent as the second step on the treatment ladder. [5, D]
- In patients for whom the previously described guidelines are not useful due to lack of efficacy, toxicity or other reasons, use of any of the DMARDs, combinations or other biologic agents is recommended; if these fail, experimental treatments should be tried. [5, D]
- Other biologic agents such as abatacept (ABT) or rituximab (RTX) are reasonable alternatives in patients who have not responded to or who have experienced toxicity with one or more anti-TNF agents.
Treatment with Glucocorticoids
- In recent-onset RA the use of low-dose oral glucocorticoids (GC) is the recommended disease-modifying therapy, always in combination with a DMARD. [1.b, A]
- In RA of long duration, the use of low-dose oral glucocorticoids is recommended as anti-inflammatory therapy for symptom control while waiting for the DMARDs to take effect. [5, D]
- Given the association between glucocorticoid use and rapid loss of bone mass, it should at a minimum be used jointly with Vitamin D and calcium, and other preventive treatments for osteoporosis should be evaluated (see section III.3.2.c. in the original guideline document) if treatment is expected to exceed 3 months. [5, D]
- The use of intra-articular glucocorticoids is essential in the management of joints that are persistently inflamed despite good therapeutic response to the DMARD regimen.
Treatment with Non-Steroidal Anti-Inflammatories (NSAIDs)
- The NSAIDs are used to modify the symptoms of RA. The use of NSAIDs is recommended at disease onset, when a new DMARD is introduced, and occasionally when uncontrolled isolated symptoms persist despite good response to a DMARD. [5, D]. The need for continuous use of NSAIDs in a patient with RA should be interpreted as inadequate control of inflammatory activity and should, therefore, lead to reassessment of the DMARD regimen. [5, D]
- All NSAIDs should be used at the full dose for at least 1 week before considering the treatment to have failed. Once symptoms have been controlled, the minimum effective dose should be used. [5, D]
- There is no evidence that some NSAIDs are better than others, therefore the one that best fits the patient characteristics should be used. [5, D]
- The need for co-treatment with gastric protectors should be evaluated on an individual basis. [5, D]
Treatment for Pain
- Analgesics are indicated to control pain. If there is no response, surgical treatment can be considered, especially to restore function and mobility. [5, D]
Treatment of RA in Special Situations
Elderly Patients
Monitoring Kidney and Liver Function
- Kidney and liver function should be monitored in elderly patients, and the dosage intervals of the drugs eliminated by these routes should be adapted accordingly. [5, D]
Monitoring Adverse Effects and Drug Interactions
- The possible appearance of adverse effects and interactions among drugs taken regularly should be monitored in elderly patients. [5, D]
Pregnancy and Breastfeeding
Prevention
- Women of childbearing age should be informed of the possible effects of RA on pregnancy, in particular, because of the implications for treatment. [5, D]
Drug Management during Pregnancy and Breastfeeding
- The use of NSAIDs during pregnancy and breastfeeding should be avoided insofar as possible. Corticosteroids can be used under controlled conditions. DMARDs should be managed on an individual basis, and should preferably be continued during pregnancy. [5, D]
Table 30 in the original guideline document shows the considerations to be taken into account with regard to DMARD use during pregnancy and breastfeeding.
For information about the safety of pharmacological treatments, including recommendations for monitoring, see Section VI and Table 31 in the original guideline document.
Other Treatments
Intra-articular Treatment
Types of Intra-articular Treatment
- The recommended local treatment of choice is intra-articular infiltration with slow-release steroids. When steroid infiltrations have failed (3 consecutive infiltrations 4 weeks apart), isotopic synovialitis or chemical synovitis with osmic acid can be considered. Before starting local treatment, the presence of infection should be reasonably ruled out. [5, D]
Rehabilitation in Rheumatoid Arthritis
Non-pharmacological Interventions
Therapeutic Exercise
- From the time of diagnosis a program of aerobic physical exercise is recommended. It should initially be supervised to adapt it to the individual's level of physical preparation and the specific joint and extra-articular circumstances stemming from the disease and comorbidities. [1.a, A]
- Aerobic exercises can be combined with muscle strengthening exercises (regional or general), and exercises to improve flexibility, coordination and manual dexterity.
Physical Treatments (Passive Modalities)
- Low level laser therapy and transcutaneous electrical nerve stimulation (TENS), used alone and independently, are effective in reducing pain in the short term (TENS has the advantage of easy application with portable units that can be used at home). [1.a, A]
- The combination of paraffin (thermotherapy) and active exercises also appears to be effective against pain. Data on ultrasound, muscular electrostimulation and magnetotherapy remain insufficient to recommend them for routine use, but they should be considered in selected cases that do not respond to other alternatives. The application of thermotherapy alone and the local application of cold do not appear to offer any clinical benefit. [2.b, B]
Integral Occupational Therapy
- In patients with important functional limitations, usually those with advanced disease, a lasting improvement has been observed. [1.b, A]
Joint Protection and Energy Conservation Programs
- In advanced phases of RA it is useful to instruct the patient about rules for joint protection. Teaching strategies to conserve energy is indicated only in patients in whom fatigue is an important symptom. [4, C]
Assistive Devices
- The use of assistive devices for important tasks should be evaluated in RA patients who have difficulties carrying out basic or instrumental activities of daily living due to weakness or lack of manual dexterity (who do not improve with an exercise program), or due to pain (that is not controlled with other therapies). [5, D]
Orthotics
Splints or Upper Limb Orthotics
- In periods of active inflammation (with the main objective of avoiding pain and reducing inflammation), static orthotics can be used (at first during the whole day and later only at night). If the patient has functional problems these can be combined during the day (part time) with functional orthotics adapted to the specific problem and to the anatomical region interfering with function. [4, C]
- Their efficacy should be evaluated periodically, and orthotics that do not meet expectations should be rejected. [5, D]
Lower Limb Orthotics
- Pain of the forefoot can be improved with hard and soft orthotics. Hard orthotics improve pain in the hindfoot in the initial phase of the disease. Use of a special model can prevent the development and progression of hallux valgus. Shoes with special widths improve the results. [1.a, A]
- Studies of orthotics are highly heterogeneous, and it is not possible to establish which type of orthotic is the most appropriate for each type of involvement. [5, D]
Balneotherapy
- Balneotherapy can be recommended in cases of polyarticular involvement without active disease, where other more accessible therapies have been ineffective. [2.b, B]
Combination Treatments. Multidisciplinary Approaches
- It is important that all professionals who participate in the treatment of the RA patient have a coordinated approach focusing on specific problems, with appropriate assessment of the effects of interventions. [5, D]
Surgical Treatment in RA
- Before performing surgical treatment, several factors should be considered: bone quality, the patient's preferences and level of motivation, estimation of the extent to which disease progression can be modified by surgery, and estimation of the degree to which surgical treatment can reconstruct joint function and improve the patient's independence. [5, D]
- The joint prosthesis is the most effective surgical measure to halt the progressive loss of functional capacity. Joint replacement, in whatever joint, should be performed before irreversible deformities become established. [5, D]
Note: This section has not been updated since GUIPCAR-2001.
Definitions:
Levels of Evidence
See Table 1, "Levels of Evidence, Oxford Centre for Evidence-Based Medicine," and the accompanying explanatory notes in the original guideline document.
Grades of Recommendation*
- Based on the results of consistent level 1 studies
- Based on the results of consistent level 2 or 3 studies or on extrapolations** from level 1 studies
- Based on the results of level 4 studies or on extrapolations* from level 2 or 3 studies
- Based on the results of level 5 studies or on troublingly inconsistent or inconclusive studies of any level
*See Table 1 in the original guideline document for an explanation of the levels of evidence according to the Oxford Classification for Evidence-Based Medicine
**"Extrapolations" are where data is used in a situation which has potentially clinically important differences than the original study situation.
clinically important differences than the original study situation.
