EULAR Updates Recommendations for the Management of Patients with Early Arthritis

VBCR - December 2016, Vol 5, No 6 - EULAR Guidelines
Anne Rowe

The treatment landscape for early arthritis continues to evolve with advances in the diagnosis and monitoring of the disease, and the use of novel effective therapies. As a result, the European League Against Rheumatism (EULAR) has updated its guidelines for the management of patients with early arthritis, which were originally published in 2007.

“These recommendations have important strengths including the composition of the expert committee comprising 20 rheumatologists, including 2 research fellows, from 12 European countries and new addition of 1 healthcare professional and 2 patient representatives,” explained Bernard Combe, MD, PhD, Director of the Research Center, Department of Rheumatology, Montpellier-Nimes University, France, and colleagues in their report.

Additional steps in the process of updating the guidelines included a literature review, which, along with 15 research questions from the 2007 recommendation development process, was used by the EULAR task force to develop the draft recommendations. This committee then identified the level of strength and category of evidence for each statement. An anonymous e-mail–based voting process was used to determine the level of agreement regarding the recommendations.

The guidelines include 12 recommendations for managing patients with early arthritis, and cover topics including recognizing arthritis, referral, diagnosis, prognostication, information, education, treatment (pharmacologic and nonpharmacologic interventions), monitoring, and management strategies. Three of the new recommendations are related to referral or diagnosis; 4 discuss initial therapy with disease-modifying antirheumatic drugs (DMARDs), nonsteroidal anti-inflammatory drugs, or glucocorticoids; 2 involve strategies for monitoring and managing the disease, and 3 cover nonpharmacologic interventions, prevention, and patient education.

Central Themes of the Recommendations

The new recommendations for the management of early arthritis include 3 overarching principles, or general statements. The first principle focuses on the importance of shared decision-making between the patient and the rheumatologist, which the panel defined as “the comprehensive process of communication, knowledge exchange and achieving consensus that should lead to a treatment decision, that is, optimal from the perspectives of both patient and clinical care provider.”

The second principle addresses the critical role of the rheumatologist in the care of patients with early arthritis. The committee behind the guideline updates acknowledged, however, that primary care physicians and other healthcare professionals who are properly trained in the management of inflammatory rheumatic diseases should be regarded as integral members of the multidisciplinary care team. In some situations, these providers may take on a larger role in the treatment of patients, if it is not feasible or cost-effective for a patient to see a specialist.

“Such care is still primarily under the responsibility and supervision of rheumatologists, but may be provided by other care providers,” Dr Combe and colleagues noted.

The third principle reiterates the importance of accurately diagnosing early rheumatoid arthritis. According to the task force, a definitive diagnosis should only be given when the patient’s history is carefully taken, and following the performance of a clinical examination, in addition to any laboratory testing or other procedures.

Highlights from the Revised EULAR Guidelines

Recommendations from the revised EULAR guidelines for the management of early arthritis include:

  • The amount of time from the onset of arthritis symptoms (eg, joint swelling associated with stiffness or pain) to the patient being referred to and seen by a rheumatologist should not exceed 6 weeks
  • The preferred method for detecting arthritis is clinical examination, although the disease may be confirmed by medical ultrasound
  • If a definitive diagnosis cannot be made in a patient with early undifferentiated arthritis, clinicians should consider risk factors for erosive and/or persistent disease (eg, the number of swollen joints, acute-phase reactants, rheumatoid factor, anticitrullinated protein antibodies, and findings from imaging studies) when determining the best management strategies
  • Patients at risk for persistent arthritis should begin therapy with DMARDs as soon as possible, and ideally within 3 months, even if they do not necessarily meet classification criteria for having an inflammatory rheumatologic disease
  • Methotrexate is recommended as the anchor drug among the class of DMARDs, and, unless contraindicated, should be a component of the first treatment strategy for patients who risk persistent disease
  • Nonsteroidal anti-inflammatory drugs are effective treatments for symptoms, but should only be administered at the lowest effective dose and for the shortest period of time acceptable following consideration of gastrointestinal, renal, and cardiovascular risks
  • Because of the increasing toxicity associated with the use of systemic glucocorticoids, these medications should only be used at the lowest dose necessary, and as short-term (ie, <6 months) adjunctive therapy. Clinicians should consider using intra-­articular glucocorticoid injections for the management of local inflammation symptoms
  • The primary aim of using DMARDs is clinical remission. Regular monitoring of disease activity, treatment-related toxicities, and comorbidities should factor into deciding which drugs are used to achieve this goal
  • Arthritis activity should be monitored through tender and swollen joint counts, global assessments by patients and clinicians, erythrocyte sedimentation rate, and C-reactive protein—usually with the use of a composite measure—and assessed at 1- to 3-month intervals until the treatment goal has been achieved. Disease activity can also be monitored using radiographic and patient-reported outcome measures (eg, functional assessments)
  • Consider using dynamic exercises, occupational therapy, and other nonpharmacologic interventions to complement drug therapy
  • Overall care of patients with early rheumatic arthritis should include smoking cessation, dental care, nutritional guidance, evaluation of vaccination status, and management of comorbidities
  • Patients should be provided with information regarding their disease, outcomes (eg, comorbidities), and all treatment options. Complementary interventions may include educational programs that can help patients cope with pain, disability, and social and vocational challenges.

When updating the 2007 guidelines, the expert committee followed the 2014 EULAR Standardised Operating Procedures. Although necessary revisions of some items were proposed, most of the major recommendations remained intact. The committee noted that additional strategies for improving the management of patients with early arthritis should be explored, including the development of new diagnostic and prognostic tools, as well as algorithms that can help to predict long-term outcomes. The panel also felt that further investigation is needed to determine the comparative effectiveness and cost-effectiveness of various modalities currently being used in the treatment of early arthritis, including the effectiveness of nonpharmacologic interventions.

The researchers asserted that these new guidelines will provide an additional useful resource for clinicians, along with EULAR’s recommendations for the management of rheumatoid arthritis with synthetic and biologic and DMARDs, which were originally published in 2010 and last updated in 2016. They noted, however, that further amendments will most likely be necessary in approximately 5 years, to reflect emerging scientific findings.

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