Intended for healthcare professionals

Rapid response to:

Practice Guidelines

Clinical assessment and management of multimorbidity: summary of NICE guidance

BMJ 2016; 354 doi: https://doi.org/10.1136/bmj.i4843 (Published 21 September 2016) Cite this as: BMJ 2016;354:i4843

Infographic 1

Adapting clinical guidelines to take account of multimorbidity

 

Infographic 2

Single condition focused vs multimorbidity approach to management

 

Chinese translation

该文章的中文翻译

Rapid Response:

Re: Clinical assessment and management of multimorbidity: summary of NICE guidance

We read your article ‘Clinical Assessment & Management of Multimorbidity: Summary of NICE Guidance’ with great interest. In response, we believe it is important to consider Rheumatoid Arthritis (RA) as a condition with a significant comorbidity burden. RA is a chronic debilitating condition affecting approximately 386,600 patients in the UK, equating to 0.81% of the population [1]. It is characterised by inflammation of the synovial joints resulting in peri-articular tissue destruction and widespread extra-articular features.

Common conditions that co-exist with RA include coronary heart disease and heart failure. A meta-analysis by Aviña‐Zubieta et al found that there was a 50% increased risk of cardiovascular-disease-related death in patients with RA, secondary to ischaemic heart disease and cerebrovascular accidents [2]. Indeed, the incidence of coronary artery disease and stroke in RA patients is the same as that in patients with Diabetes Mellitus [3,4]. Other common comorbidities include chronic pain [5] and depression. In a systematic review conducted by Matcham et al, the prevalence of major depressive disorder in patients with RA was found to be 16.8%, with the prevalence of depression as 38.8% [6].

Polypharmacy is also a significant problem in RA patients. A study by Treharne et al (2008) found that the mean total number of medications per patient was 5.39, with only 2.41 of these being directly for RA, on average [7]. Many patients with RA are on disease-modifying-anti-rheumatic drugs (DMARDs), such as methotrexate. In the past, this medication was stopped when patients were having elective surgery performed. However, a study by Grennan et al found that continuation of methotrexate treatment did not increase the risk of infection or surgical complications in patients undergoing elective orthopaedic surgery, and thus it should not be stopped in patients whose disease is controlled by the drug [8]. All RA patients undergoing surgery should have pre-operative blood tests to check bone marrow suppression and liver function.

When treating patients with rheumatoid arthritis, it is important to consider the full comorbidity burden in order to provide a holistic approach to management. The guidelines that have been set out in your article would therefore be particularly pertinent to this selection of patients.

1. D. Symmons et al, The prevalence of rheumatoid arthritis in the United Kingdom: new estimates for a new century Rheumatology (2002) 41 (7): 793-800 doi:10.1093/rheumatology/41.7.793

2. Aviña‐Zubieta JA, Choi HK, Sadatsafavi M, Etminan M, Esdaile JM, Lacaille D. Risk of cardiovascular mortality in patients with rheumatoid arthritis: A meta‐analysis of observational studies. Arthritis Care & Research. 2008 Dec 15;59(12):1690-7.

3. del Rincon, I., Williams, K., Stern, M.P., Freeman, G.L. and Escalante, A., 2001. High incidence of cardiovascular events in a rheumatoid arthritis cohort not explained by traditional cardiac risk factors. Arthritis & Rheumatism, 44(12), pp.2737-2745.

4. Van Halm, V.P., Peters, M.J.L., Voskuyl, A.E., Boers, M., Lems, W.F., Visser, M., Stehouwer, C.D.A., Spijkerman, A.M.W., Dekker, J.M., Nijpels, G. and Heine, R.J., 2009. Rheumatoid arthritis versus diabetes as a risk factor for cardiovascular disease: a cross-sectional study, the CARRE Investigation. Annals of the rheumatic diseases, 68(9), pp.1395-1400.

5. Heiberg, T. and Kvien, T.K., 2002. Preferences for improved health examined in 1,024 patients with rheumatoid arthritis: pain has highest priority. Arthritis Care & Research, 47(4), pp.391-397.

6. Matcham, F., Rayner, L., Steer, S. and Hotopf, M., 2013. The prevalence of depression in rheumatoid arthritis: a systematic review and meta-analysis. Rheumatology, 52(12), pp.2136-2148.

7. Treharne, G.J., Douglas, K.M.J., Iwaszko, J., Panoulas, V.F., Hale, E.D., Mitton, D.L., Piper, H., Erb, N. and Kitas, G.D., 2007. Polypharmacy among people with rheumatoid arthritis: the role of age, disease duration and comorbidity. Musculoskeletal Care, 5(4), pp.175-190.

8. Grennan, D.M., Gray, J., Loudon, J. and Fear, S., 2001. Methotrexate and early postoperative complications in patients with rheumatoid arthritis undergoing elective orthopaedic surgery. Annals of the rheumatic diseases, 60(3), pp.214-217.

Competing interests: No competing interests

25 October 2016
NEHA A PANDA
Junior Doctor (FY2)
Michael A Clynes, Richard Hull
Rheumatology Department, Queen Alexandra Hospital, Southwick Hill Road, Portsmouth, PO6 3LY