Intended for healthcare professionals

Practice Guidelines

Diagnosis and management of rheumatoid arthritis in adults: summary of updated NICE guidance

BMJ 2018; 362 doi: (Published 03 August 2018) Cite this as: BMJ 2018;362:k3015
  1. Alex Allen, senior research fellow1,
  2. Serena Carville, guideline lead and associate director1,
  3. Frank McKenna, clinical lead and consultant rheumatologist2
  4. on behalf of the Guideline Development Group
  1. 1National Guideline Centre, Royal College of Physicians, London NW1 4LE, UK
  2. 2Trafford General Hospital, Manchester University NHS Foundation Trust, Manchester M41 5SL, UK
  1. Correspondence to: F McKenna Frank.Mckenna{at}

What you need to know

  • Aim for remission or low disease activity as the target for treatment

  • To begin treatment, use one disease modifying anti-rheumatic drug (DMARD) and increase the dose, before adding another DMARD, if needed

  • Consider short term bridging therapy with glucocorticoids when starting a new conventional synthetic DMARD

  • Consider oral non-steroidal anti-inflammatory drugs (NSAIDs) for uncontrolled pain or stiffness

  • Offer the lowest effective dose of NSAID for the shortest possible time, with a proton pump inhibitor and review risk factors for adverse events regularly

Rheumatoid arthritis is a chronic, disabling autoimmune disease characterised by synovitis of small and large joints causing swelling, stiffness, pain, and progressive joint destruction. About 1% of the UK population have rheumatoid arthritis, and approximately 15% of these people have severe disease. It affects roughly three times as many women as men. People tend to develop rheumatoid arthritis between 40 and 60 years of age, although it can arise at any age. The early signs of rheumatoid arthritis are often encountered in primary care, where people present with joint pain and swelling. Fast and accurate referral to rheumatology services is important to achieve early remission and prevent or reduce disability.1

This article summarises the update of the National Institute for Health and Care Excellence (NICE) guideline for the diagnosis and management of rheumatoid arthritis in adults.2 The management of rheumatoid arthritis has evolved in the nine years since the previous NICE guideline on rheumatoid arthritis was published, with greater emphasis on a treat-to-target strategy rather than specific drug regimens,3 and debate about the merit of initiating treatment with combination drug therapy.4 Technologies such as ultrasound have been increasingly used for diagnosis and monitoring of synovitis where it is unclear from clinical examination.5 These aspects of management were investigated by the Guideline Committee, and …

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