Intended for healthcare professionals

Practice Guidelines

Management of rheumatoid arthritis: summary of NICE guidance

BMJ 2009; 338 doi: (Published 16 March 2009) Cite this as: BMJ 2009;338:b702
  1. Chris Deighton, consultant rheumatologist 1,
  2. Rachel O’Mahony, senior research fellow 2,
  3. Jonathan Tosh, health economist3,
  4. Claire Turner, project manager2,
  5. Michael Rudolf, consultant physician4
  6. on behalf of the Guideline Development Group
  1. 1Department of Rheumatology, Derbyshire Royal Infirmary, Derby DE1 2QY
  2. 2National Collaborating Centre for Chronic Conditions, Royal College of Physicians of London NW1 4LE
  3. 3Health Economics and Decision Science, ScHARR, University of Sheffield, Sheffield S10 2TN
  4. 4Department of Respiratory Medicine, Ealing Hospital, Ealing UB1 3HW
  1. Correspondence to: C Deighton chris.deighton{at}

    Why read this summary?

    Rheumatoid arthritis is a chronic, progressive autoimmune disease associated with inflammation principally in synovial joints and affecting over 400 000 people in the United Kingdom.1 In recent years it has become clear that pain and disability can be avoided if the disease is recognised early and treated promptly and appropriately. It is therefore crucial that all health professionals have knowledge of the recognition, management, and appropriate referral of patients with rheumatoid arthritis. This article summarises the recommendations in the guideline from the National Institute for Health and Clinical Excellence (NICE) on the management of rheumatoid arthritis, from early identification to managing chronic and severe disease.2


    NICE recommendations are based on systematic reviews of best available evidence. When minimal evidence is available, recommendations are based on the opinion of the Guideline Development Group (GDG) of what constitutes good practice. Evidence levels for the recommendations are given in italic in square brackets.

    Referral, diagnosis, and investigations

    • Refer for specialist opinion anyone with suspected persistent synovitis of undetermined cause. Refer urgently even if blood tests show a normal acute-phase response or negative rheumatoid factor and if:

      • -The small joints of the hands or feet are affected

      • -More than one joint is affected, or

      • -There has been a delay of three months or longer between symptom onset and seeking medical advice.

    [Based on high and moderate quality observational studies of early prognosis and identification or diagnosis]

    • Offer to test for rheumatoid factor in people with suspected rheumatoid arthritis who have synovitis. [Based on high and moderate quality early identification observational studies]

    • Consider measuring anticyclic citrullinated peptide antibodies in people with suspected rheumatoid arthritis if:

      • -They are negative for rheumatoid factor, and

      • -Combination therapy is being considered (see section on disease modifying antirheumatic drugs).

    [Based on data from case series]

    • X ray …

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