The National Institute for Health and Clinical Excellence and the National Collaborating Centre for Chronic Conditions have published new guidelines to speed diagnosis and improve the management of rheumatoid arthritis in the country.

Around 400,000 people in the UK suffer from RA, a condition characterised by inflammation of the joints, causing pain, swelling and stiffness. Often referred to as an autoimmune disease because it is the body’s own immune system which “attacks” the joints, RA has no cure, and so treatment is currently focused on slowing the progression of the condition and providing pain relief to patients.

Early diagnosis and subsequent treatment of RA can help to slow disease progression and reduce the chance of damage the joints, and this forms a central theme of the recommendations, which are designed to ensure that doctors act on symptoms as early as possible getting patients faster access to therapy.

In terms of treatment, it is recommended that newly diagnosed patients be offered a combination of disease modifying anti-rheumatic drugs (including methotrexate and at least one other DMARD, plus short-term glucocorticoids) as first-line treatment, ideally within three months of the onset of persistent symptoms.

In addition, the guidelines describe a whole host of interventions that should be offered to patients to help them better cope with their condition, such as specialist physiotherapy. Patients should also have access to a named member of a multidisciplinary team who is responsible for coordinating care, as well as periodic assessments of how the disease is affecting various aspects of the patient’s life, such as pain and ability to work.

Closing the gap
A report by think tank The King's Fund last year found “striking gulfs” in the diagnosis and care of RA and a lack of clinical understanding about the disease across England and Wales. But Dr Michael Rudolf, Chair of the Guideline Development Group, said the new guidelines will “help make sure that everyone with [RA] benefits from a consistent national approach to managing the condition”, and that it “sets standards for the best ways to support and treat patients with RA, thus helping to end the existing variation in practice and improving standards of care”.

The National Rheumatoid Arthritis Society has also welcomed the new guideline and called for its “swift and widespread” implementation. Its chief executive Ailsa Bosworth commented: “The guideline is clear that all patients should be tightly managed, particularly in the early stages of disease which should improve long term outcomes”. Furthermore, she said it “will help patients understand what constitutes best practice in managing RA, and realise that putting up with uncontrolled symptoms doesn’t have to be an option.”

Decision on anti-TNFs outstanding
Last year, the Institute published issued a positive opinion on the use of anti-tumour necrosis factor (TNF) inhibitors – namely Abbott Laboratories’ Humira (adalimumab), Amgen/Wyeth’s Enbrel (etanercept) and Remicade (infliximab), which is manufactured by Johnson & Johnson and sold by Schering-Plough outside the USA – for the treatment of RA, but ruled against their sequential use.

However, the fact that patients would not be able to try a different anti-TNF if treatment with the first failed angered patients, companies and charities alike, and an appeal against the decision was launched.

The Appeal Board ruled in November that NICE’s guidance was “perverse in light of the evidence submitted”, and it recommended that the sequential use of these drugs, after failure of the first, should be restarted as a new appraisal.

A spokesperson for NICE has confirmed to PharmaTimes that the Institute is still waiting to hear from the Department of Health on whether a new formal referral for this is required.

Final guidance for flu
Meanwhile, the Institute has also published final guidance for the treatment of flu, recommending treatment with Roche’s Tamiflu (oseltamivir) and GlaxoSmithKline’s Relenza (zanamivir) if: national surveillance indicates circulation of influenza virus A or B; the person is in an ‘at-risk’ group; the patient presents with an influenza-like illness and can start treatment within 48 hours (or 36 hours for Relenza in children) of symptom onset.

This guidance expands on previous recommendations issued in 2003 in that it now considers people with chronic neurological conditions and chronic liver disease ‘at risk’, and recommends Relenza as a treatment option for children in ‘at-risk’ groups aged five to 12 years old.