Healthcare Service Improvement Team
Primary and secondary
prevention of rheumatoid
arthritis
Author: Norma Prosser, Dr Mary Webb, Public Health Specialists
Date: 11 June 2010
Version: 1
Publication/ Distribution:

Public (Internet)
Review Date: A review of this document is not planned by Public Health
Wales NHS Trust.
Purpose and Summary of Document:
The document has been produced to assist local health boards to implement
the Commissioning Directive on Arthritis and Chronic Musculoskeletal
Conditions, and should be read in conjunction with that publication.
This is an evidence-based summary of effective interventions for primary
and secondary prevention of rheumatoid arthritis.
Smoking is indicated as a risk factor and prompt diagnosis and treatment
recommended for those suspected of rheumatoid arthritis were identified
from the available evidence.
Work Plan reference: HS02
Public Health Wales
Primary and secondary prevention of
rheumatoid arthritis
CONTENTS
1
BACKGROUND ......................................................................... 3
2
RHEUMATOID ARTHRITIS ....................................................... 3
2.1 Introduction ......................................................................... 3
2.2 Search methodology ............................................................. 4
2.3 Prevalence ........................................................................... 5
2.4 Hospital admissions .............................................................. 5
3
PRIMARY PREVENTION ........................................................... 7
4
SECONDARY PREVENTION ...................................................... 7
5
FURTHER INFORMATION ........................................................ 7
6.
REFERENCES ........................................................................... 9
© 2010 Public Health Wales NHS Trust.
Material contained in this document may be reproduced without prior permission
provided it is done so accurately and is not used in a misleading context.
Acknowledgement to Public Health Wales NHS Trust to be stated.
Date: 11 June 2010
Version: 1
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1
Primary and secondary prevention of
rheumatoid arthritis
Background
This document has been produced to assist local health boards to
implement the Welsh Assembly Government’s, Designed for people with
chronic conditions, Service development and commissioning directives,
Arthritis and chronic musculoskeletal conditions1, and should be read in
conjunction with that publication.
A key action identified in Chapter 2: Prevention – reducing the risks (p.9)
of the publication, is evidence-based primary and secondary prevention1.
From the key categories identified in the commissioning directive (p.2),
the aim in this document is the identification of currently available
information and evidence-based literature with a focus on rheumatoid
arthritis.
To supplement the evidence–base, and provide an overview of the topic,
information with regard to prevalence (where available); hospital
admissions (where information is available from Patient Episode Database
Wales, PEDW); and links to additional information resources have been
included. The links to further information resources is included to indicate
where additional details, or management and treatment guidance can be
sought.
The information contained in this document is not exhaustive.
2
Rheumatoid arthritis
2.1
Introduction
Inflammatory arthritis conditions cause inflammation in the joints, and
symptoms can include severe pain, stiffness, fatigue, deformity and
reduced joint function. Joints and organs can be affected, and severe
inflammatory arthritis can significantly shorten life expectancy.
Inflammatory arthritis includes some of the most severe, painful and
disabling musculoskeletal conditions, some of which start in children or
young adulthood. Conditions include rheumatoid arthritis, ankylosing
spondylitis, psoriatic arthritis and juvenile idiopathic arthritis1, 2.
Sero-negative arthritis is used by doctors as an umbrella term for two
different conditions: sero-negative rheumatoid arthritis and seronegative
spondyloarthropathy. The term refers to inflammatory diseases, where
there is inflammation and swelling, but the rheumatoid factor is absent.
The presence of rheumatoid factor (during a blood test) is commonly used
to diagnose rheumatoid arthritis3. It is not known what causes a person to
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Primary and secondary prevention of
rheumatoid arthritis
develop inflammatory arthritis. Various factors may be relevant, including
the environment, infection, trauma and a person’s genetic make-up4.
Rheumatoid arthritis (RA) is an inflammatory disease that exerts its
greatest impact on those joints of the body that are lined with synovium, a
specialised tissue responsible for maintaining the nutrition and lubrication
of the joint. The distribution of joints affected (synovial joints) is
characteristic. It typically affects the small joints of the hands and the
feet, and usually both sides equally in a symmetrical distribution, though
any synovial joint can be affected. In patients with established and
aggressive disease, most joints will be affected over time2.
The triggers that cause RA are unknown. There is evidence to suggest that
abnormalities in components of the immune system lead to the body
developing abnormal immune and inflammatory reactions, particularly in
joints, these changes may precede the symptomatic onset of RA by many
years2.
The risk factors commonly associated with RA4 are: female sex;
 family history: this may make someone more susceptible to RA;
 following a viral infection: some people develop RA;
 smoking: has been shown to be a well established environmental
risk factor associated with increased risk of RA2, 3.
There is some suggestion that individuals who had a birthweight over 10
pounds, are twice as likely to develop rheumatoid arthritis when they are
adults, compared with individuals born with an average birthweight. This
cohort data requires further investigation5.
2.2
Search methodology
Search terms: primary prevention, secondary prevention, rheumatoid
arthritis.
Search terms were kept broad to maximise retrieval of literature and
search limits set to retrieve papers published between January 2003 to
January 2010.
Electronic databases: Medline; Embase; Cochrane Database of Systematic
Reviews; Database of Abstracts of Reviews of Effects; Cochrane Central
Register of Controlled Trials and British Nursing Index.
Meta search engines: Turning Research Into Practice (TRIP); Google
Scholar; SUMsearch.
Websites: NHS Evidence; International Network of Agencies for Health
Technology Assessment (INAHTA); National Institute for Health and
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Primary and secondary prevention of
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Clinical Excellence (NICE); National Horizon Scanning Centre and Map of
Medicine; UpToDate.
2.3
Prevalence
There are approximately 400,000 (0.8%) people with RA in the UK. There
is an estimated rate of 1.5 males per 10,000 population per year, and 3.6
females. This equates to approximately 12,000 new diagnoses of RA each
year in the UK, occurring 2–4 times more in women than men. The peak
age of incidence in the UK for both genders is in the 70s, but with a long
tail on either side, indicating that all ages can develop the disease2.
2.4
Hospital admissions
Figure 1: Persons admitted to hospital in Wales 2000-2006 with a principal
diagnosis of inflammatory arthritis including rheumatoid arthritis (ICD -10, M05
to M14) by Unitary Authority
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1600
1400
1200
1000
800
600
400
200
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ng
Admissions
Persons admitted to hospital with a principal diagnosis of inflammatory
arthritis including rheumatoid arthritis 2000-2006
Unitary Authority
Source: PEDW
Figure 2: Persons admitted to hospital in Wales 2000-2006 with a principal
diagnosis of inflammatory arthritis including rheumatoid arthritis (ICD -10, M05
to M14) by Local Health Board
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Primary and secondary prevention of
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Admisisons
Persons admitted to hospital with a principla diagnosis of inflammatory
arthrits including rheumatoid arthritis 2000-2006
4500
4000
3500
3000
2500
2000
1500
1000
500
0
Betsi C adwaladr
University
Powys
Hywel Dda
Abertawe Bro
Morgannwg
C ardiff and Vale
University
C wm Taf
Aneurin Bevan
Local Health Board
Source: PEDW
Table 1: Persons admitted to hospital in Wales 2000-2006 with a principal
diagnosis of inflammatory arthritis including rheumatoid arthritis (ICD -10,
M05 to M14)
Local Health Board
Betsi Cadwaladr University
Powys
Hywel Dda
Abertawe Bro Morgannwg
Cardiff and Vale University
Cwm Taf
Aneurin Bevan
Source: PEDW
Date: 11 June 2010
Unitary Authority
Isle of Anglesey
Gwynedd
Conwy
Denbighshire
Flintshire
Wrexham
Powys
Ceredigion
Pembrokeshire
Carmarthenshire
Swansea
Neath Port Talbot
Bridgend
Vale of Glamorgan
Cardiff
Rhondda Cynon Taff
Merthyr Tydfil
Caerphilly
Blaenau Gwent
Torfaen
Monmouthshire
Newport
Total
Version: 1
Admissions
276
520
610
487
568
626
653
250
556
824
1243
1822
1055
522
1342
1856
426
921
406
397
337
532
1622
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Primary and secondary prevention of
rheumatoid arthritis
Primary prevention
Although smoking is an identified risk factor in some reports3, 4 it has been
suggested that there are no modifiable risk factors indicated to allow
consideration of primary prevention strategies for RA6.
4
Secondary prevention
Management recommendations for suspected RA in adults are consistent
with early inflammatory arthritis: individuals should be identified and
assessed as soon as possible, and for those with the early stages of RA
that correct diagnosis is made by expert assessment2, 7.
The benefit of early intervention with disease modifying anti-rheumatic
drugs (DMARDs) compared with delayed treatment is well established. The
recommendation is that there is a need for diagnosis and treatment ideally
within 3 months of the onset of symptoms2, 6, 8.
5
Further information
The British Society for Rheumatology:
 Kennedy T et al. BSR guidelines on standards of care for persons
with rheumatoid arthritis. Rheumatology 2005;44:553–6. Available
at:
http://www.rheumatology.org.uk/includes/documents/cm_docs/2009/s
/standards_of_care_for_persons_with_rheumatoid_arthritis.pdf
[Accessed 2nd Jun 2010]
 Luqmani R et al. British Society for Rheumatology and British Health
Professionals in Rheumatology guideline for the management of
rheumatoid arthritis (The first 2 years). Rheumatology 2006;
doi:10.1093/rheumatology/kel215b. Available at:
http://www.rheumatology.org.uk/includes/documents/cm_docs/2009/
m/management_of_rheumatoid_arthritis_first_2_years.pdf
[Accessed 2nd Jun 2010]
 Luqmani R et al. British Society for Rheumatology and British Health
Professionals in Rheumatology guideline for the management of
rheumatoid arthritis (after the first 2 years). Rheumatology 2009;
doi:10.1093/rheumatology/ken450b. Available at:
http://www.rheumatology.org.uk/includes/documents/cm_docs/209/m
/management_of_rheumatoid_arthritis_after_first_2_years.pdf
[Accessed 2nd Jun 2010]
 Ledingham J et al. Update on the British Society for Rheumatology
guidelines for prescribing TNFa blockers in adults with rheumatoid
arthritis (update of previous guidelines of April 2001). Rheumatology
2005;44:157–63. Available at:
http://www.rheumatology.org.uk/includes/documents/cm_docs/2009/
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p/prescribing_tnf_blockers_in_adults_with_rheumatoid_arthritis.pdf
[Accessed 2nd Jun 2010]
Clinical Knowledge summaries:
 Rheumatoid arthritis.
http://www.cks.nhs.uk/home [Accessed 2nd Jun 2010]
European League Against Rheumatism:
 European Bone and Joint Health Strategies Project. European action
towards better musculoskeletal health. A public health strategy to
reduce the burden of musculoskeletal conditions. Lund: University
Hospital; 2004. Available at:
http://ec.europa.eu/health/ph_projects/2000/promotion/fp_promotion
_2000_exs_15_en.pdf [Accessed 2nd Jun 2010]
House of Commons, Committee of Public Accounts:
 Services for people with rheumatoid arthritis. Tenth report of session
2009-10. Available at:
http://www.publications.parliament.uk/pa/cm200910/cmselect/cmpub
acc/46/46.pdf [Accessed 2nd Jun 2010]
Map of Medicine:
 Rheumatoid arthritis (RA) – suspected;
 Extra-articular disease - rheumatoid arthritis;
 Rheumatoid arthritis (RA) – medical treatment;
 Safe use of methotrexate
http://nhsevidence.mapofmedicine.com/evidence/map/index.html
[Accessed 2nd Jun 2010]
NHS Evidence Musculoskeletal [Website]:
 2009 annual evidence update on rheumatoid arthritis (RA). Available
at:
http://www.library.nhs.uk/musculoskeletal/viewResource.aspx?resid=
312000&code=1e1a34321cfa3c61e46364558a411620 [Accessed 2nd
Jun 2010]
National Institute for Health and Clinical Excellence:
 Rheumatoid arthritis: the management of rheumatoid arthritis in
adults. CG79. London: NICE; 2009.Available at:
http://guidance.nice.org.uk/CG79 [Accessed 2nd Jun 2010]
 Etanercept and infliximab for the treatment of rheumatoid arthritis.
TA36. London: NICE; 2002. Available at:
http://guidance.nice.org.uk/TA36 [Accessed 2nd Jun 2010]
 Rituximab for the treatment of rheumatoid arthritis. TA126. London:
NICE; 2007. Available at: http://guidance.nice.org.uk/TA126
[Accessed 2nd Jun 2010]
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Primary and secondary prevention of
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Adalimumab, etanercept and infliximab for the treatment of
rheumatoid arthritis. TA130. London: NICE; 2007. Available
at:http://guidance.nice.org.uk/TA130 [Accessed 2nd Jun 2010]
Abatacept for the treatment of rheumatoid arthritis. TA141.London:
NICE; 2008. Available at: http://guidance.nice.org.uk/TA141
[Accessed 2nd Jun 2010]
Certolizumab pegol for the treatment of rheumatoid arthritis. TA186.
London: NICE; Available at:
http://guidance.nice.org.uk/TA186 [Accessed 2nd Jun 2010]
References
1.
Welsh Assembly Government. Designed for people with chronic
conditions. Service Development and Commissioning Directives.
Arthritis and chronic musculoskeletal conditions. Cardiff: WAG; 2007.
Available at: http://www.wales.nhs.uk/documents/FinalArthritis_English.pdf [Accessed 3rd Dec 2009]
2.
National Institute for Health and Clinical Excellence. Rheumatoid
arthritis the management and treatment of rheumatoid arthritis in
adults. CG79. London: NICE; 2009. Available at:
http://guidance.nice.org.uk/CG79 [Accessed 3rd Dec 2009]
3.
Pedersen M et al. Environmental risk factors differ between
rheumatoid arthritis with and without auto-antibodies against cyclic
citrullinated peptides. Arthritis Res Ther 2006: 8:R133. Available at:
http://arthritis-research.com/content/8/4/R133 [Accessed 3rd Dec
2009]
4.
NHS choices your health, your choices. Rheumatoid arthritis.
Available at:
http://www.nhs.uk/pathways/rheumatoidarthritis/Pages/Avoiding.asp
x [Accessed 3rd Dec 2009]
5.
Mandl LA et al. Is birthweight associated with risk of rheumatoid
arthritis? Data from a large cohort study. Ann Rheum Dis 2009;
68:514-518. Available at:
http://www.ncbi.nlm.nih.gov/pubmed/18593757 [Accessed 3rd Dec
2009]
6.
Arthritis Community Research and Evaluation Unit University Health
Network. Care for people with arthritis: evidence and best practices.
Toronto: ACREU; 2005. Available at:
http://www.acreu.ca/pdf/pub5/05-05.pdf [Accessed 3rd Dec 2009]
7.
Combe B et al. EULAR recommendations for the management of
early arthritis: report of a task force of the European Standing
Committee for International Clinical Studies Including Therapeutics
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(ESCISIT). Ann Rheum Dis 2007; 66:34. Available at:
http://ard.bmj.com/content/66/1/34.full?keytype=ref&siteid=bmjjour
nals&ijkey=gX5c.9%2FvOKyDk [Accessed 3rd Dec 2009]
8.
Emery P, Nam J, Villeneuve E. [Online]. 2008, how early should
treatment be started in RA? 2007. Available at:
http://www.library.nhs.uk/musculoskeletal/ViewResource.aspx?resID
=282842&tabID=29 [Accessed 3rd Dec 2009]
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