This site is intended for health professionals only

At the heart of general practice since 1960

NICE urges rheumatoid arthritis patients to seek specialist care during flare-ups

New NICE guidelines say rheumatoid arthritis patients should seek out 'specialist care' if their disease worsens of flares up.

The new recommendations, published earlier this week, also says every patient diagnosed with rheumatoid arthritis should receive anti-CCP antibody testing, to determine the severity of their condition.

This can be carried out in primary care to aid diagnosis, or in secondary care after diagnosis.

The new guideline says: ‘If anti-CCP antibodies are present or there are erosions on X-ray… emphasise the importance of monitoring their condition and seeking rapid access to specialist care if disease worsens or they have a flare.’

Other recommendations include:

  • Consider measuring anti-CCP antibodies in adults with suspected RA if they are negative for rheumatoid factor
  • Measure functional ability using, for example, the Health Assessment Questionnaire, to provide a baseline for assessing the functional response to treatment
  • Advise the person that they have an increased risk of radiological progression but not necessarily an increased risk of poor function, if anti-CCP antibodies are present or there are erosions on X-ray

A NICE spokesperson said: ‘The guideline now strengthens the previous recommendation around anti-CCP antibody testing for some people with suspected RA by recommending that everyone with a diagnosis of RA is now given the test.

‘This is because evidence shows that people who test positive for anti-CCP antibodies - and who have damage to their joints which shows up on an X-ray - have a higher risk of developing more severe RA and need to be advised of the importance of monitoring their condition.'

But BMA GP Committee clinical and prescribing policy lead Dr Andrew Green said: 'The most important thing for GPs to realise is that a negative anti-CCP test does not rule out significant disease and the referral should be made on clinical grounds. We know that early intervention makes a real difference to patients’ long-term outcomes and urgent appointments must be readily available.

'Many GPs find rheumatoid factor an expensive and unhelpful test and not useful for assessing the need for specialist opinion. One-stop MSK centres organised with good GP support may have a role to play in ensuring timely access.'

GPs have previously been told to discuss the impact of being overweight on treatment outcomes with rheumatoid arthritis patients, after a new study found that those with healthy BMIs are more likely to achieve sustained disease remission than those who are overweight.

Recommendations in full

Referral from primary care

1.1.1 Refer for specialist opinion any adult with suspected persistent synovitis of undetermined cause. Refer urgently (even with a normal acute-phase response, negative anti-cyclic citrullinated peptide [CCP] antibodies or rheumatoid factor) if any of the following apply:

  • the small joints of the hands or feet are affected
  • more than one joint is affected
  • there has been a delay of 3 months or longer between onset of symptoms and seeking medical advice. [2009, amended 2018]

Investigations

If the following investigations are ordered in primary care, they should not delay referral for specialist opinion.

Investigations for diagnosis

1.1.3 Consider measuring anti-CCP antibodies in adults with suspected RA if they are negative for rheumatoid factor. [2009, amended 2018]

1.1.4 X-ray the hands and feet in adults with suspected RA and persistent synovitis. [2009, amended 2018]

Investigations following diagnosis

1.1.5 As soon as possible after establishing a diagnosis of RA:

  • measure anti-CCP antibodies, unless already measured to inform diagnosis
  • X-ray the hands and feet to establish whether erosions are present, unless X-rays were performed to inform diagnosis
  • measure functional ability using, for example, the Health Assessment Questionnaire (HAQ), to provide a baseline for assessing the functional response to treatment. [2018]

1.1.6 If anti-CCP antibodies are present or there are erosions on X-ray:

  • advise the person that they have an increased risk of radiological progression but not necessarily an increased risk of poor function, and
  • emphasise the importance of monitoring their condition, and seeking rapid access to specialist care if disease worsens or they have a flare. [2018]

Source:  NICE

Readers' comments (8)

  • GPs should be able to identify patients with suspected inflammatory arthritis and refer directly to rheum, urgently for new diagnosis. An intervening ‘MSK’ service, probably run by physios, adds no value for inflammatory arthritis. I hope all GPs test for anti CCP already when considering inflammatory arthritis.

    Unsuitable or offensive? Report this comment

  • Hmm refer urgently, well I do that but the patient will not get seen for 3-6 months

    Unsuitable or offensive? Report this comment

  • NICE should shut up until it can back up its 'recommendations' with workforce planning and money. I think NICE is one of the reasons the NHS is in the hole it is in right now - patients are entitled as 'NICE guidelines say choice and I want this medication'.
    also used as a stick to beat us with when we havent gone the NICE route medicolegally

    Unsuitable or offensive? Report this comment

  • Beaker where are you that new inflammatory arthritis patients take 6 months to be seen? I thought urgent reviews for such patients has been the case for some time? A positive anti ccp in primary care helps these patients get triaged to urgent rheum.

    Unsuitable or offensive? Report this comment

  • Vinci Ho

    Have been testing BOTH Rheumatoid Factor and Anti-CCP last 7-8 years for suspected symmetrical synovitis , polyarthropathy etc . Thanks to the availability of our local laboratory. But not every region provides the test , I presume?
    Rheumatology is like dermatology in terms of OPD waiting time. The commencement of disease modifying drugs is so restricted that a waiting of 3-6 months to see rheumatologists is a social norm in NHS. This recommendation to start treatment in ASAP in clear cut proven cases , is easy said than done.....

    Unsuitable or offensive? Report this comment

  • so as we wait for 3mths or so, if NSAIDS not helping, can nice agree that gp start steroids? then assess /take care of osteoporosis as well; as it seems by the time rheum sees patients hands may have started to deform..

    Unsuitable or offensive? Report this comment

  • Northern Ireland (northern board at least) seem to be making up their own guidelines; as they go along -in this area. They are refusing all rheumatoid factor tests on grounds that anti-CCP testing is enough.

    Unsuitable or offensive? Report this comment

  • we cant even get shared care amber list patients seen for years and years and years so there is no hope of this advice being taken seriously by secondary care either,

    Unsuitable or offensive? Report this comment

Have your say