EULAR Updates Early Arthritis Management Recommendations

The European League Against Rheumatism (EULAR) has published an update to its recommendations for the management of early arthritis. The advisory panel, which originally met in January 2016, comprised more than 20 experts from 12 European countries. Their findings and recommendations – last updated in 2007 – were recently published in the Annals of the Rheumatic Diseases.¹

“The management of early arthritis has changed considerably in the past few years under the influence of new concepts for diagnosis and new effective therapies,” the EULAR panel wrote. Earlier diagnosis and treatment is more feasible since the first guidelines were issued. “Beyond doubt, the treatment goal of early arthritis should now be clinical remission and prevention of joint destruction,” the advisory panel noted.

The EULAR panel issued principles and recommendations for the management of early arthritis after receiving suggestions presented during an in-person meeting in January 2016, followed by anonymized email voting for each recommendation.

Overarching Principles

1. Management of early arthritis should aim for the best care and must be based on a shared decision between the patient and the rheumatologist 
2. Rheumatologists are the specialists who should primarily care for patients with early arthritis  
3. A definitive diagnosis in a patient with early arthritis should only be made after careful history taking and clinical examination, which should also guide laboratory testing and additional procedures

2016 EULAR Recommendations

• Patients presenting with arthritis (any joint swelling associated with pain or stiffness) should be referred to, and seen by, a rheumatologist within 6 weeks after the onset of symptoms. 
• Clinical examination is the method of choice for detecting arthritis, which may be confirmed by ultrasonography.
• If a definitive diagnosis cannot be reached and the patient has early undifferentiated arthritis, risk factors for persistent and/or erosive disease— including number of swollen joints, acute phase reactants, rheumatoid factor, anticitrullinated peptide antibodies (ACPAs) and imaging findings— should be considered in management decisions.
• Treatment with disease-modifying antirheumatic drugs (DMARDs) should be started as early as possible (ideally within 3 months) in patients at risk for persistent arthritis, even if they do not fulfill classification criteria for an inflammatory rheumatologic disease. 
• Among the DMARDs, methotrexate is considered the anchor drug and, unless contraindicated, should be part of the first treatment strategy in patients at risk for persistent disease. 
• Nonsteroidal anti-inflammatory drugs (NSAIDs) are effective symptomatic therapies but should be used at the minimum effective dose for the shortest time possible, after evaluation of gastrointestinal, renal, and cardiovascular risks. 
• Systemic glucocorticoids reduce pain, swelling, and structural progression, but in view of their cumulative adverse effects, they should be used at the lowest dose necessary as temporary (<6 months) adjunctive treatment. Intra-articular glucocorticoid injections should be considered for the relief of local symptoms of inflammation. 
• The main goal of DMARD treatment is to achieve clinical remission, and regular monitoring of disease activity, adverse events, and comorbidities should guide decisions on choice and changes in treatment strategies to reach this target. 
• Monitoring of disease activity should include tender and swollen joint counts, patient and physician global assessments, erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP), usually by applying a composite measure. Arthritis activity should be assessed at 1-month to 3-month intervals until the treatment target has been reached. Radiographic and patient-reported outcome measures, such as functional assessments, can be used to complement disease activity monitoring.
• Nonpharmacologic interventions, such as dynamic exercises and occupational therapy, should be considered as adjuncts to drug treatment in patients with early arthritis.
• Smoking cessation, dental care, weight control, assessment of vaccination status, and management of comorbidities should be part of overall care in patients with early arthritis.
• Patient information concerning the disease, its outcome (including comorbidities), and its treatment is important. Education programs aimed at coping with pain, disability, maintenance of ability to work, and social participation may be used as adjunct interventions.  

Summary and Clinical Applicability

Compared with the 2007 guidelines, the 2016 recommendations moved one recommendation to the third overarching principle spot, regarding the definitive diagnosis in a patient with early arthritis. A slight change in the first recommendation added the words “within 6 weeks” after the onset of symptoms. This amendment was issued because, “After 2005,” the committee wrote, “two studies have confirmed that patients with inflammatory arthritis in general, and those with suspected RA in particular, should be referred to a rheumatologist as early as possible.^2,3”

A prevention recommendation was added in this update (bullet point #11). This includes items such as smoking cessation, dental care, weight control, assessment of vaccination status, and management of comorbidities, which should be included as part of overall patient care for those with early arthritis. 

The published recommendations also feature useful algorithms for clinicians to consider during (1) diagnosis and prognosis and (2) treatment and strategy associated with the management of early arthritis.  

Disclosures

Dr Combe has received honoraria from Bristol-Myers Squibb (BMS), Janssen, Eli Lilly, Merck, Novartis, Pfizer, Roche-Chugai, Sanofi, and UCB, and research grants from Pfizer, Roche-Chugai, and UCB. Dr Landewe has received honoraria and/or research grants from AbbVie, Ablynx, Amgen, AstraZeneca, Bristol-Myers Squibb, Celgene, Janssen, Galapagos, GlaxoSmithKline (GSK), Novartis, Novo-Nordisk, Merck, Pfizer, Roche, Schering-Plough, TiGenix, and UCB; he is also director of Rheumatology Consultancy BV. Dr Daien has received honoraria from BMS, Merck, Pfizer, Roche-Chugai, and UCB. Dr Aletaha has received honoraria from AbbVie, BMS, Centocor, Janssen, Eli Lilly, Medac, Merck, Pfizer, Roche, and UCB. Dr Álvaro-Gracia has received honoraria from AbbVie, BMS, MSD, Novartis, Pfizer, Roche, Sanofi, and UCB, and research grants from MSD, Pfizer, Roche, and UCB. Dr Burmester has received honoraria from AbbVie, BMS, Janssen, Eli Lilly, MSD, Novartis, Pfizer, Roche-Chugai, and UCB, and research grants from Pfizer, Roche-Chugai, and UCB. Dr Codreanu has received speaker and consulting fees from AbbVie, Amgen, Angellini, AstraZeneca, BMS, Egis, MSD, Pfizer, Richter, Roche, Sanofi, Servier, Teva, UCB, and Zentiva. Dr Conway has received honoraria from AbbVie, Roche, Pfizer and Amgen. Dr Dougados has received honoraria for participating at advisory boards or symposia organized by Pfizer, AbbVie, UCB, Roche, Eli Lilly, Novartis, Sanofi, Merck, and BMS; his department has received research grants from Pfizer, AbbVie, UCB, Roche, Eli Lilly, Novartis, Sanofi, Merck, and BMS. Dr Emery has provided expert advice for AbbVie, AstraZeneca, BMS, Eli Lilly, Merck, Novartis, Pfizer, Roche, Sandoz, Samsung, and UCB. Dr Ferraccioli has received honoraria from AbbVie, Pfizer, MSD, Roche, Janssen, Eli Lilly, and UCB and research grants from Roche and MSD. Dr Fonseca has received unrestricted research grants or acted as a speaker for AbbVie, Amgen, BMS, Biogen, Celltrion, Celgene, Hospira, Janssen, MSD, Novartis, Novo-Nordisk, Pfizer, Roche, and UCB. Dr Raza has received honoraria from AbbVie, Pfizer, Roche, and Janssen and research grants from AbbVie. Dr Smolen has received grants for his institution from AbbVie, Janssen, Eli Lilly, MSD, Pfizer, and Roche and has provided expert advice to and/or had speaking engagements for AbbVie, Amgen, AstraZeneca, Astro, Celgene, Celltrion, GSK, ILTOO, Janssen, Eli Lilly, Medimmune, MSD, Novartis-Sandoz, Pfizer, Roche, Samsung, Sanofi, and UCB. Dr Szekanecz has received consultant and speakers fees from AbbVie, MSD, Bristol-Myers Squibb, Roche, and Pfizer. Dr Kvien has received fees for speaking and/or consulting from Biogen, BMS, Boehringer Ingelheim, Celltrion, Eli Lilly, Epirus, Hospira, Merck-Serono, Novartis, Orion Pharma, Pfizer, Sandoz, and UCB. Dr van Vollenhoven has received research support and grants from AbbVie, Amgen, BMS, GSK, Pfizer, Roche, and UCB, and honoraria for consultancy from AbbVie, Biotest, BMS, Celgene, Crescendo, GSK, Janssen, Eli Lilly, Merck, Novartis, Pfizer, Roche, UCB, and Vertex.

References

1. Combe B, Landewe R, Daien CI, et al. 2016 update of the EULAR recommendations for the management of early arthritis [published online December 15, 2016]. Ann Rheum Dis. doi:10.1136/annrheumdis-2016-210602
2. van der Linden MPM, le Cessie S, Raza K, et al. Long-term impact of delay in assessment of patients with early arthritis. Arthritis Rheum. 2010;62:3537-3546.
3. Feldman DE, Bernatsky S, Houde M, et al. Early consultation with a rheumatologist for RA: does it reduce subsequent use of orthopaedic surgery? Rheumatology (Oxford). 2013;52:452-459.

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