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EULAR updates recommendations for managing early arthritis

Jairia Dela Cruz
05 Jan 2017

Patients with early arthritis should be allowed to share in the decision making regarding the approach to treatment, with rheumatologists acting as the primary specialists, according to the 2016 update of the European League Against Rheumatism (EULAR) recommendations for early arthritis management.

“While these ‘recommendations’ are deliberately not called ‘guidelines’, they do reflect a strong view of many European experts including patient representatives,” the authors said.

“They should provide rheumatologists, general practitioners, medical students, healthcare professionals, health authorities and patients a practical approach to the management of early arthritis, even though each healthcare professional should choose the most appropriate management strategy for each individual patient,” they added.

A committee—which included 20 rheumatologists, 2 patients and 1 healthcare professional from 12 European countries—reconsidered the 2007 recommendations and formulated new ones based on the research questions and the results of a systematic literature research.

Upon report of the proposed recommendations, the committee members voted anonymously by email and indicated their level of agreement for each item on a scale of 0 to 10 (with 10 designated as complete agreement).

The update resulted in a total of 12 recommendations. Key changes were embodied in three overarching principles stating that early arthritis management should allow shared decision making between patients and physicians, the primary specialist to manage these patients must be a rheumatologist, and a definitive diagnosis requires careful history taking and clinical examination.

Consulting a rheumatologist is recommended within 6 weeks after onset of any joint swelling associated with pain or stiffness. Arthritis may be confirmed by ultrasonography.

Disease-modifying antirheumatic drugs (DMARDs) should be initiated within 3 months ideally in patients at risk of persistent arthritis, regardless of meeting classification criteria for an inflammatory rheumatologic disease.  

Methotrexate should be considered in the first-line setting unless contraindicated. On the other hand, symptomatic treatment with nonsteroidal anti-inflammatory drugs (NSAIDs) is effective but should be used at the minimum effective dose for the shortest time possible, and following assessment of gastrointestinal, renal and cardiovascular risks.

Tender and swollen joint counts, patient's and physician's global assessments, erythrocyte sedimentation rate and C-reactive protein have to be included in the monitoring of disease activity. Assessments can be performed at 1- to 3-month intervals until achievement of the treatment target.

Interventions such as dynamic exercises and occupational therapy, as well as educational programmes aimed at coping with pain and promoting social participation may be given as an adjunct to pharmacological treatment. Moreover, smoking cessation, dental care, weight control, assessment of vaccination status and management of comorbidities should be part of overall patient care.

The authors noted that despite important recent advances, the committee believed that prompt and accurate diagnosis and prognosis of early arthritis warranted new tools, including new biomarkers, better understanding of the added value of ultrasonography and MRI, and creation of prediction algorithms for long-term outcome.

“[T]he expert committee [also] felt that the comparative effectiveness and cost-effectiveness of the different strategic modalities in early arthritis, including the effectiveness of nonpharmacological interventions, need additional research,” the authors added.

The recommendations are published online December 2016 in the Annals of the Rheumatic Diseases.

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Audrey Abella, 17 Oct 2017
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