guidelines

rheumatoid arthritis (ra) in adults

nice-based recognition and management of rheumatoid arthritis: early referral, baseline assessment, treat-to-target principles, and practical monitoring considerations.

last reviewed: 2026-02-13
based on: NICE NG100 (published 11 Jul 2018; last updated 12 Oct 2020; last reviewed 19 Nov 2024)
reviewer: Dr Kola Tytler MBBS CertHE MBA MRCGP
view official NICE source

Recognition: don’t miss early inflammatory arthritis

  • Typical features: persistent synovitis, morning stiffness >30–60 minutes, small joint involvement (MCP/PIP), symmetrical pattern, systemic fatigue.
  • Investigations (primary care): RF and anti-CCP (useful but not definitive), CRP/ESR, baseline FBC/LFT/U&Es. Negative serology does not exclude RA.
  • Urgency: early rheumatology access matters—delays increase erosive disease risk.

First-line management (shared care mindset)

  • Refer: people with suspected persistent synovitis (particularly small joints, multiple joints, or positive anti-CCP) for specialist assessment.
  • Symptom control while awaiting: NSAIDs if safe (consider PPI and renal risk) and/or short courses of corticosteroids may be used under local protocols; document infection risk screening if steroids are used.
  • DMARD strategy: RA is usually treated with DMARDs early and to a treat-to-target plan. Initiation is typically specialist-led, with structured monitoring and shared-care arrangements.

Monitoring, safety, and comorbidities

  • Baseline screens before immunosuppression vary by DMARD/biologic (often hepatitis/TB risk assessment via specialist).
  • Vaccinations: optimise influenza, pneumococcal, and shingles strategy before/while on immunosuppressants (avoid live vaccines where contraindicated).
  • Cardiovascular risk: RA increases CVD risk—treat BP/lipids aggressively; encourage exercise, smoking cessation, weight optimisation.
  • Flares: consider infection triggers; avoid repeatedly escalating steroids without a clear plan and specialist input.

Frequently asked questions

Do I need positive RF/anti-CCP to refer?
No. Persistent clinical synovitis warrants referral regardless of serology, particularly when small joints are involved or symptoms persist.
Can I start methotrexate in primary care?
In many systems initiation is specialist-led due to baseline screening, dosing, and monitoring complexity. If you have a local shared-care protocol supporting GP initiation, follow it precisely.
What is the single biggest lever for long-term outcomes?
Early diagnosis and early DMARD therapy under a treat-to-target approach—meaning prompt rheumatology access and adherence support.

Transparency

This page is an educational, clinician-written summary of publicly available NICE guidance intended for trained healthcare professionals. It uses original wording (not copied text) and should be used alongside the full NICE source, local pathways, and clinical judgement. Doses provided are for general reference; always check the BNF/SPC.