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Rapid response to:

Practice Guidelines

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

BMJ 2018; 362 doi: https://doi.org/10.1136/bmj.k3015 (Published 03 August 2018) Cite this as: BMJ 2018;362:k3015

Rapid Response:

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

Mind the [evidence] gap.

How sad for our patients with Rheumatoid Arthritis that the NICE Guidelines total summary of 'Symptom control' is NSAIDs and perhaps low dose steroids, albeit with no guidance on dose or route. Rather sheepishly, the authors acknowledge that this could be 'challenging'. There is a clear lack of patient influence on this position and I ironically read the Editorial on Patient Participation in the same issue. What has gone wrong with NICE Guidance? Reading the feedback concerning the value of 'Evidence-based Medicine' elsewhere in the same BMJ issue it strikes me that the RA Guideline is a lovely example of how a lack of RCT evidence leads to a hole in what patients view as the most important area of their own management. All other evidence levels and the staggeringly narrow Scoping exercises and internal processes cripple (pun intended) the finished article which then gets picked up by Commissioners, Educationalists and Non-Specialists. No wonder patient feedback on current Rheumatology services' approach to pain, fatigue and stiffness is scathing and headlines in the Telegraph (1,2).

On reflection, perhaps NICE could have referenced a signpost to other Guidelines on Pain Management and 'Symptom control'. Perhaps a mention to a holistic assessment of a patient's symptoms using tools such as a Brief Pain Inventory or RA Impact of Disease score? EULAR Guidelines (3), just published and thus not included in NICE Guideline literature searches are a good place to start for those interested in this endeavour.

1. Arthritis Research UK / Daily Telegraph. April 2016.
2. NRAS. Spotlight on RA: Perspective on living and treating rheumatoid arthritis. May 2016.
3. Geenen R, Overman CL, Christensen R, et al. Ann Rheum Dis doi:10.1136/annrheumdis-2017-212662

Competing interests: Chair of MSK Pain SIG for the BSR

30 August 2018
Nicholas G Shenker
Rheumatologist
Cambridge University Hospital
Box 204, Addenbrooke's Hospital, Hills Road, Cambridge, UK, CB2 0QQ