Managing rheumatoid

arthritis
A NICE pathway brings together all NICE guidance, quality
standards and materials to support implementation on a specific
topic area. The pathways are interactive and designed to be used
online. This pdf version gives you a single pathway diagram and
uses numbering to link the boxes in the diagram to the associated
recommendations.
To view the online version of this pathway visit:
http://pathways.nice.org.uk/pathways/rheumatoid-arthritis
Pathway last updated: 26 March 2015. To see details of any updates to this pathway since its launch,
visit: About this Pathway. For information on the NICE guidance used to create this path, see:
Sources.
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Managing rheumatoid arthritis

Rheumatoid arthritis pathway

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Person with rheumatoid arthritis

No additional information

Management by the multidisciplinary team

Offer people with rheumatoid arthritis access to:

a multidisciplinary team for periodic assessments of the effect of rheumatoid arthritis on
their lives (such as pain, fatigue, everyday activities, mobility, ability to work or take part in
social or leisure activities, quality of life, mood, impact on sexual relationships) and help to
manage the condition
a named member of the multidisciplinary team (for example, the specialist nurse) who is
responsible for coordinating their care
psychological interventions (for example, relaxation, stress management and cognitive
coping skills [such as managing negative thinking])
specialist occupational therapy, with periodic review, if they have:
difficulties with everyday activities, or
problems with hand function
specialist physiotherapy, with periodic review, to:
improve general fitness and encourage regular exercise
learn exercises for joint flexibility, muscle strength and managing other functional
impairments
learn about the short-term pain relief from methods such as TENS and wax baths
a podiatrist for assessment and periodic review if they have foot problems. Offer functional
insoles and therapeutic footwear if indicated.
For information about periodic review, see monitoring and review in this pathway.

Diet and complementary therapies

Inform people who wish to experiment with their diet that there is no strong evidence their
rheumatoid arthritis will benefit. However, they could be encouraged to eat a Mediterraneanstyle diet (more bread, fruit, vegetables and fish; less meat; and replace butter and cheese with
products based on vegetable and plant oils).

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If a person with rheumatoid arthritis decides to try complementary therapies, this should not
prejudice the attitudes of members of the multidisciplinary team or affect the care offered.
Advise people:
there is little evidence for the long-term efficacy of complementary therapies
they should continue with their normal treatment.

Drug treatment for rheumatoid arthritis

See Rheumatoid arthritis / Drug treatment for rheumatoid arthritis

Timing and referral for surgery

Offer to refer people with rheumatoid arthritis for an early specialist surgical opinion if any of the
following do not respond to optimal non-surgical management:
persistent pain due to joint damage or other identifiable soft tissue cause
worsening joint function
progressive deformity
persistent localised synovitis.
Offer to refer people with any of the following complications for a specialist surgical opinion
before damage or deformity becomes irreversible:
imminent or actual tendon rupture
nerve compression (for example, carpal tunnel syndrome)
stress fracture.
When surgery is offered to people with rheumatoid arthritis, explain that cosmetic improvements
should not be the dominant concern and the main expected benefits are:
pain relief
improvement, or prevention of further deterioration, of joint function, and
prevention of deformity.
Offer urgent combined medical and surgical management to people with rheumatoid arthritis
who have suspected or proven septic arthritis (especially in a prosthetic joint).

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If a person with rheumatoid arthritis develops any symptoms or signs that suggest cervical
myelopathy (for example, paraesthesiae, weakness, unsteadiness, reduced power, extensor
plantars):
request an urgent MRI scan, and
refer for a specialist surgical opinion.
Do not let concerns about the long-term durability of prosthetic joints influence decisions to
offer joint replacements to younger people with rheumatoid arthritis.

Guidance on relevant surgical interventions

Total hip replacement and resurfacing arthroplasty for end-stage arthritis of the hip
Prostheses for total hip replacement and resurfacing arthroplasty are recommended as
treatment options for people with end-stage arthritis of the hip only if the prostheses have rates
(or projected rates) of revision of 5% or less at 10 years.
These recommendations are from total hip replacement and resurfacing arthroplasty for endstage arthritis of the hip (review of technology appraisal guidance 2 and 44). (NICE technology
appraisal guidance 304).
NICE has written information for the public explaining the guidance on prostheses for end-stage
hip arthritis.
Interventional procedures
NICE has published guidance on the following procedures with normal arrangements for
clinical governance, consent and audit:
Total prosthetic replacement of the temporomandibular joint (NICE interventional procedure
guidance 500)
Minimally invasive total hip replacement (NICE interventional procedure guidance 363)
Shoulder resurfacing arthroplasty (NICE interventional procedure guidance 354)
Metatarsophalangeal joint replacement of the hallux (NICE interventional procedure
guidance 140)
NICE has published guidance on the following procedure with special arrangements for
clinical governance, consent and audit or research:

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Total wrist replacement (NICE interventional procedure guidance 271)

Resources
The following implementation tool is relevant to this part of the pathway.
Total hip replacement and resurfacing arthroplasty for end stage arthritis of the hip (review of
technology appraisal guidance 2 and 44): costing statement

Monitoring and review

See Rheumatoid arthritis / Rheumatoid arthritis overview / Monitoring and review

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Glossary
Recent-onset
Disease duration of up to 2 years.
Established rheumatoid arthritis
Disease duration of longer than 2 years.
DMARDs
Disease-modifying anti-rheumatic drugs.
TNF
Tumour necrosis factor.
DAS28
Disease activity score.
NSAIDs
Non-steroidal anti-inflammatory drugs.
COX-2
Cyclo-oxygenase 2.
MoM
Metal on metal.
TMJ
Temporomandibular joint.
TENS
Transcutaneous electrical nerve stimulators.
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Sources
Rheumatoid arthritis (2009) NICE clinical guideline 79
Total hip replacement and resurfacing arthroplasty for end stage arthritis of the hip (review of
technology appraisal guidance 2 and 44) (2014) NICE technology appraisal guidance 304
Total prosthetic replacement of the temporomandibular joint (2014) NICE interventional
procedure guidance 500
Minimally invasive total hip replacement (2010) NICE interventional procedure guidance 363
Shoulder resurfacing arthroplasty (2010) NICE interventional procedure guidance 354
Total wrist replacement (2008) NICE interventional procedure guidance 271
Metatarsophalangeal joint replacement of the hallux (2005) NICE interventional procedure
guidance 140

Your responsibility
The guidance in this pathway represents the view of NICE, which was arrived at after careful
consideration of the evidence available. Those working in the NHS, local authorities, the wider
public, voluntary and community sectors and the private sector should take it into account when
carrying out their professional, managerial or voluntary duties. Implementation of this guidance
is the responsibility of local commissioners and/or providers. Commissioners and providers are
reminded that it is their responsibility to implement the guidance, in their local context, in light of
their duties to avoid unlawful discrimination and to have regard to promoting equality of
opportunity. Nothing in this guidance should be interpreted in a way which would be inconsistent
with compliance with those duties.

Copyright
Copyright National Institute for Health and Care Excellence 2015. All rights reserved. NICE
copyright material can be downloaded for private research and study, and may be reproduced
for educational and not-for-profit purposes. No reproduction by or for commercial organisations,
or for commercial purposes, is allowed without the written permission of NICE.

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Contact NICE
National Institute for Health and Care Excellence
Level 1A, City Tower
Piccadilly Plaza
Manchester
M1 4BT
www.nice.org.uk
nice@nice.org.uk
0845 003 7781

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