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EULAR Updates Recommendations for Early Arthritis
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EULAR has provided an update to its 2007 recommendations for the management of early arthritis, according to a recently published report.
“While these ‘recommendations’ are deliberately not called ‘guidelines,’ they do reflect a strong view of many European experts including patient representatives,” Bernard Combe, MD, professor in the Rheumatology Department at Montpellier University in France and member of the EULAR committee, and colleagues wrote.
EULAR formed an expert committee, including 20 rheumatologists, two patients and one health care professional, representing a total of 12 European countries. The committee determined the target population, defined “management” and then selected research questions. Two fellows performed a systematic literature review with the help of a librarian. Based on the research questions and literature review, the committee made the following 12 recommendations:
- Patients who present with any joint swelling associated with pain or stiffness should be referred to a rheumatologist within 6 weeks of onset;
- For detecting arthritis, clinical examination is the method of choice and ultrasonography can be used for confirmation;
- If definite diagnosis cannot be achieved and the patient has early undifferentiated arthritis, clinicians should consider risk factors for persistent or erosive disease — which include swollen joints, acute phase reactants, rheumatoid factor, anti-citrullinated protein antigen and imaging findings — in management decisions;
- Patients at risk for persistent arthritis should be started on disease-modifying antirheumatic drugs (DMARDs) as soon as possible, but ideally within 3 months, even if they do not fulfill criteria for an inflammatory rheumatologic disease;
- Unless contraindicated, methotrexate should be a part of the first treatment strategy in patients at risk for persistent disease;
- NSAIDs should be used at the minimum effective dose for the shortest time possible after evaluation of gastrointestinal, renal and cardiovascular risks;
- Systemic glucocorticoids should be used at the lowest dose necessary as temporary adjunctive treatment, which is less than 6 months, and intra-articular glucocorticoid injections should be considered for the relief of local inflammation symptoms;
- Remission is the primary goal of DMARD treatment, which should be guided by regular monitoring of disease activity, adverse events and comorbidities;
- Monitoring of disease activity should occur at 1-month to 3-month intervals until treatment target is reached and should include tender and swollen joint counts, patient and physician global assessments, as well as erythrocyte sedimentation rate and C-reactive protein, which can be complemented by radiographic and patient-reported outcome measures, such as functional assessments;
- Non-pharmacologic interventions, such as dynamic exercise and occupational therapy, should be considered as adjuncts to drug treatment;
- Smoking cessation, dental care, weight control, assessment of vaccination status and comorbidity management should be a part of overall care; and
- Educational programs for coping with pain, disability, maintenance of ability to work and social participation may be used as adjunct interventions.
“[The] committee felt that further development of new tools is needed for early and accurate diagnosis and prognosis, including new biomarkers, better understanding of the added value of [ultrasound] US and MRI and creation of prediction algorithms for long-term outcome,” Combe and colleagues wrote. “Finally, the expert committee felt that the comparative effectiveness and cost-effectiveness of the different strategic modalities in early arthritis, including the effectiveness of non-pharmacological interventions, need additional research.” – by Will Offit
Disclosures: Combe reports honoraria from BMS, Janssen, Eli Lilly, Merck, Novartis, Pfizer, Roche-Chugai, Sanofi and UCB as well as research grants from Pfizer, Roche-Chugai and UCB. Please see the full study for a list of all other relevant financial disclosures.
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