Clinical Rheumatology

, Volume 30, Issue 1, pp 103–106

Treating early rheumatoid arthritis intensively: current UK practice does not reflect guidelines

Brief Report


Recent guidance published in the UK by the National Institute for Health and Clinical Excellence has recommended that patients with early rheumatoid arthritis (RA) are treated with combination disease-modifying anti-rheumatic drugs (DMARDs). It is unclear to what extent this reflects current UK practice. UK rheumatologists were asked to complete a web-based questionnaire asking about their treatment preferences in early RA and to indicate their attitudes to combination DMARD therapy. Although the majority was using step-up combination DMARDs, only 50% of the 258 respondents were using initial combination therapy in any patients with newly diagnosed RA despite scoring it highly for efficacy and safety. Concerns were expressed about side effects, increased monitoring requirements, and acceptability to patients. Current UK practice does not reflect the recently published guidelines. Uncertainties remain as to which patients need combination therapy and the optimal regimes to use. Further research is required to elucidate attitudes to aggressive therapy in early disease.


Attitude Drug therapy Drug therapy, combination Questionnaires Rheumatoid arthritis Therapeutics 


  1. 1.
    National Institiute for Health and Clinical Excellence (2009) Rheumatoid arthritis: national clincal guideline for management and treatment in adults.
  2. 2.
    McCarty DJ (1981) Treating intractable rheumatoid arthritis. N Engl J Med 305:1009–1011CrossRefPubMedGoogle Scholar
  3. 3.
    Boers M, Verhoeven AC, Markusse HM, van de Laar MA, Westhovens R, van Denderen JC, van Zeben D, Dijkmans BA, Peeters AJ, Jacobs P, van den Brink HR, Schouten HJ, van der Heijde DM, Boonen A, van der LS (1997) Randomised comparison of combined step-down prednisolone, methotrexate and sulphasalazine with sulphasalazine alone in early rheumatoid arthritis. Lancet 350:309–318CrossRefPubMedGoogle Scholar
  4. 4.
    O'Dell JR, Haire CE, Erikson N, Drymalski W, Palmer W, Eckhoff PJ, Garwood V, Maloley P, Klassen LW, Wees S, Klein H, Moore GF (1996) Treatment of rheumatoid arthritis with methotrexate alone, sulfasalazine and hydroxychloroquine, or a combination of all three medications. N Engl J Med 334:1287–1291CrossRefPubMedGoogle Scholar
  5. 5.
    Mottonen T, Hannonen P, Leirisalo-Repo M, Nissila M, Kautiainen H, Korpela M, Laasonen L, Julkunen H, Luukkainen R, Vuori K, Paimela L, Blafield H, Hakala M, Ilva K, Yli-Kerttula U, Puolakka K, Jarvinen P, Hakola M, Piirainen H, Ahonen J, Palvimaki I, Forsberg S, Koota K, Friman C (1999) Comparison of combination therapy with single-drug therapy in early rheumatoid arthritis: a randomised trial. FIN-RACo trial group. Lancet 353:1568–1573CrossRefPubMedGoogle Scholar
  6. 6.
    Combe B, Landewe R, Lukas C, Bolosiu HD, Breedveld F, Dougados M, Emery P, Ferraccioli G, Hazes JM, Klareskog L, Machold K, Martin-Mola E, Nielsen H, Silman A, Smolen J, Yazici H (2007) EULAR recommendations for the management of early arthritis: report of a task force of the European Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT). Ann Rheum Dis 66:34–45CrossRefPubMedGoogle Scholar
  7. 7.
    Luqmani R, Hennell S, Estrach C, Birrell F, Bosworth A, Davenport G, Fokke C, Goodson N, Jeffreson P, Lamb E, Mohammed R, Oliver S, Stableford Z, Walsh D, Washbrook C, Webb F (2006) British Society for Rheumatology and british health professionals in Rheumatology guideline for the management of rheumatoid arthritis (the first two years). Rheumatology (Oxford) 45:1167–1169CrossRefGoogle Scholar
  8. 8.
    van der Kooij SM, de Vries-Bouwstra JK, Goekoop-Ruiterman YP, van Zeben D, Kerstens PJ, Gerards AH, van Groenendael JH, Hazes JM, Breedveld FC, Allaart CF, Dijkmans BA (2007) Limited efficacy of conventional DMARDs after initial methotrexate failure in patients with recent onset rheumatoid arthritis treated according to the disease activity score. Ann Rheum Dis 66:1356–1362CrossRefPubMedGoogle Scholar
  9. 9.
    Choy EH, Smith C, Dore CJ, Scott DL (2005) A meta-analysis of the efficacy and toxicity of combining disease-modifying anti-rheumatic drugs in rheumatoid arthritis based on patient withdrawal. Rheumatology (Oxford) 44:1414–1421CrossRefGoogle Scholar
  10. 10.
    Saag KG, Teng GG, Patkar NM, Anuntiyo J, Finney C, Curtis JR, Paulus HE, Mudano A, Pisu M, Elkins-Melton M, Outman R, Allison JJ, Suarez AM, Bridges SL Jr, Chatham WW, Hochberg M, MacLean C, Mikuls T, Moreland LW, O'Dell J, Turkiewicz AM, Furst DE (2008) American College of Rheumatology 2008 recommendations for the use of nonbiologic and biologic disease-modifying antirheumatic drugs in rheumatoid arthritis. Arthritis Rheum 59:762–784CrossRefPubMedGoogle Scholar
  11. 11.
    Jobanputra P, Wilson J, Douglas K, Burls A (2004) A survey of British rheumatologists' DMARD preferences for rheumatoid arthritis. Rheumatology (Oxford) 43:206–210CrossRefGoogle Scholar
  12. 12.
    Mikuls TR, O'Dell J (2000) The changing face of rheumatoid arthritis therapy: results of serial surveys. Arthritis Rheum 43:464–465CrossRefPubMedGoogle Scholar
  13. 13.
    van Tuyl LH, Plass AM, Lems WF, Voskuyl AE, Dijkmans BA, Boers M (2007) Why are Dutch rheumatologists reluctant to use the COBRA treatment strategy in early rheumatoid arthritis? Ann Rheum Dis 66:974–976CrossRefPubMedGoogle Scholar
  14. 14.
    van Tuyl LH, Plass AM, Lems WF, Voskuyl AE, Kerstens PJ, Dijkmans BA, Boers M (2008) Discordant perspectives of rheumatologists and patients on COBRA combination therapy in rheumatoid arthritis. Rheumatology (Oxford) 47:1571–1576CrossRefGoogle Scholar
  15. 15.
    Goekoop-Ruiterman YP, de Vries-Bouwstra JK, Allaart CF, Kerstens PJ, Grillet BA, de Jager MH, Han KH, Speyer I, van der Lubbe PA, Seys PE, Breedveld FC, Dijkmans BA (2007) Patient preferences for treatment: report from a randomised comparison of treatment strategies in early rheumatoid arthritis (BeSt trial). Ann Rheum Dis 66:1227–1232CrossRefPubMedGoogle Scholar
  16. 16.
    Kirwan JR, Chaput de Saintonge DM, Joyce CR, Holmes J, Currey HL (1986) Inability of rheumatologists to describe their true policies for assessing rheumatoid arthritis. Ann Rheum Dis 45:156–161CrossRefPubMedGoogle Scholar
  17. 17.
    Kiely P, Williams R, Walsh D, Young A (2009) Contemporary patterns of care and disease activity outcome in early rheumatoid arthritis: the ERAN cohort. Rheumatology (Oxford) 48:57–60CrossRefGoogle Scholar

Copyright information

© Clinical Rheumatology 2010

Authors and Affiliations

  • Toby Garrood
    • 1
  • Warren Shattles
    • 2
  • David L. Scott
    • 3
  1. 1.Department of RheumatologyGuy’s HospitalLondonUK
  2. 2.Department of RheumatologyEast Surrey HospitalRedhillUK
  3. 3.Academic Department of Rheumatology, Kings College LondonWeston Education CentreLondonUK

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