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Rheumatoid Arthritis (RA)

NICE guideline [NG100] Rheumatoid arthritis in adults: management. Last updated: Oct 2020.

Guidelines

Refer for specialist opinion in any adult with synovitis of undetermined cause.

Refer urgently if ANY of the following (even if normal acute phase reactant and -ve antibodies):
  • Small joints of the hands or feet affected
  • >1 joint affected
  • Delay of ≥3 months between symptom onset and seeking medical advice

Do not delay referral by ordering the following investigations, in primary care the top priority is referral.

1st line tests:
  • Rheumatoid factor, and
  • X-ray of the hand and feet

If rheumatoid factor is -ve → consider measuring anti-CCP antibodies
  • If a diagnosis of RA is made, make sure to measure anti-CCP antibodies, if not already

Treatment target in active RA is:
  • Complete remission, or
  • Low disease activity (treat-to-target), if remission not possible
 

Offer short-term glucocorticoid therapy to manage flares.

Not stated in NICE, but standard practice for choosing the route of steroids:
  • Oral for systemic flares affecting multiple joints
  • Intra-articular injection for mono or oligo flares
  • IM injection when oral not appropriate

In addition to DMARDs (outlined below), also consider oral NSAIDs when control of pain or stiffness is inadequate

Step up treatment if treatment target has not been achieved despite dose escalation.
 

Conventional DMARD monotherapy with oral methotrexate / leflunomide / sulfasalazine
  • To be started ASAP and ideally within 3 months of symptom onset
  • Consider hydroxychloroquine in mild RA or palindromic rheumatism
 

Consider short-term bridging steroid therapy (oral / IM / intra-articular) when starting a new DMARD.

Add a conventional DMARD to the existing monotherapy, any of the following:
  • Methotrexate
  • Leflunomide
  • Sulfasalazine
  • Hydroxychloroquine

If no adequate response to 2 conventional DMARDs used in combination → offer methotrexate + biological DMARD

Choice of biological DMARD:
  • 1st line: TNF inhibitors (adalimumab, etanercept, infliximab)
  • 2nd line:
    • JAK inhibitors (filgotinib, tofacitinib, baricitinib, upadacitinib)
    • T cell inhibitor (abatacept)
  • If severe RA (DAS28 >5.1) inadequately responded to at least 1 TNF inhibitor → rituximab (+ methotrexate)
 
 

Disclaimer: NICE did not make recommendations on what classes of biological DMARDs, instead it provides separate technology appraisals for individual biological DMARDs which is confusing and complicated.For educational purposes, the above section is written in line with standard clinical practice and textbook approaches that is frequently tested in exams, while taking NICE guidelines into account.

Measure / assess the following to monitor treatment:
  • CRP
  • DAS28
  • Health Assessment Questionnaire (HAQ) to measure functional ability

References

Author: Adams Lau
Reviewer:
Last edited: 22/07/25