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Guidelines for managing rheumatoid arthritis

How should patients with newly diagnosed rheumatoid arthritis be managed?

How should patients with newly diagnosed rheumatoid arthritis be managed?


These European guidelines were developed by an expert committee of rheumatologists.

The group assembled all research information after searching several databases, and attempted to answer their questions with the best available evidence, using the AGREE instrument to evaluate the relevance of recommendations.

Expert opinion was used when good evidence was unavailable. The group focused on research evaluating the effect of management on the development of erosions and loss of function.

The recommendations have not been tested in practice.

The group produced 12 recommendations. They suggest treatment should begin quickly, ideally within six weeks of initial diagnosis (level of evidence: good).

Prognosis should be attempted by evaluating the number of affected joints, markers of inflammation, and evidence on X-ray of erosions.

The guidelines do not give specific recommendations as to how to weigh these findings when determining the need for aggressive therapy (level of evidence: low-quality).

Based on observational studies, patients who seem to be at risk of developing persistent or erosive rheumatoid arthritis should be treated quickly with disease-modifying antirheumatic drugs (DMARDs).

Based on effectiveness and safety evidence, methotrexate should be started in most patients. Therapy should start within six weeks of symptom onset, even if patients do not completely meet the criteria for diagnosis.

NSAIDs and systemic or local steroids should be used for pain control. Exercise, occupational therapy and hydrotherapy should be used as adjuncts to maintain function and decrease pain (level of evidence: good).

These guidelines are similar to the guidelines from the British Society for Rheumatism and are a little more aggressive than those from the American College of Rheumatology.

Level of evidence

5 (see


Combe B, Landewe R, Lukas C, et al. EULAR recommendations for the management of early arthritis: report of a taskforce of the European Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT). Ann Rheum Dis 2007;66:34-45.

Bottom line: These guidelines, from the European League Against Rheumatism, recommend early diagnosis and rapid initiation of treatment with DMARDs even before the patient's symptoms meet official criteria for rheumatoid arthritis.

For most patients the initial choice of DMARD is methotrexate. Anti-inflammatory drug therapy, exercise, occupational therapy and hydrotherapy should be used to treat pain and maintain function.

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