NICE's clinical guideline CG79 for managing rheumatoid arthritis takes a two-fold approach to pharmacological therapies: drugs to suppress rheumatic disease, and drugs to help with symptoms.20

Disease modifying anti-rheumatic drugs (DMARDs), glucocorticoids and biological drugs fall into the first group. The BNF points out that DMARDs can take two to six months for a full therapeutic response, and selection of DMARD should factor in co-morbidities and patient preferences.21

DMARD treatment should commence ideally within three months of the onset of permanent symptoms, typically using a combination (methotrexate and one other) and a short-term corticosteroid. €In patients with established and stable rheumatoid arthritis, cautiously reduce drug doses to the lowest that are clinically effective.€

For symptom management (ie pain control), the NICE guidelines have been adapted from recommendations around managing osteoarthritis. As such, it says: €Offer analgesics (for example, paracetamol, codeine or compound analgesics) to people with RA whose pain control is not adequate, to potentially reduce their need for long-term treatment with NSAIDs or COX-2 inhibitors.€20

Other advice is similar:

·       use oral NSAIDs/COX-2 inhibitors at the lowest effective dose for the shortest possible time;

·       including PPI therapy alongside an NSAID or COX-2 inhibitor

·       manage side effect risk effectively.

In addition: €If NSAIDs or COX-2 inhibitors are not providing satisfactory symptom control, review the disease-modifying or biological drug regimen.€