OBJECTIVE: Rheumatoid arthritis (RA) is a chronic autoimmune inflammatory disorder with a global prevalence of approximately 0.5-1%. Patients with RA are at an increased risk of developing comorbidities (eg, cardiovascular disease, pulmonary disease, diabetes and depression). Despite this, there are limited recommendations for the management and implementation of associated comorbidities. This study aimed to identify good practice interventions in the care of RA and associated comorbidities. METHODS: A combination of primary research (180+ interviews with specialists across 12 European rheumatology centres) and secondary research (literature review of existing publications and guidelines/recommendations) were used to identify challenges in management and corresponding good practice interventions. Findings were prioritised and reviewed by a group of 18 rheumatology experts including rheumatologists, comorbidity experts, a patient representative and a highly specialised nurse. RESULTS: Challenges throughout the patient pathway (including delays in diagnosis and referral, shortage of rheumatologists, limited awareness of primary care professionals) and 18 good practice interventions were identified in the study. The expert group segmented and prioritised interventions according to three distinct stages of the disease: (1) suspected RA, (2) recent diagnosis of RA and (3) established RA. Examples of good practice interventions included enabling self-management (self-monitoring and disease management support, for example, lifestyle adaptations); early arthritis clinic; rapid access to care (online referral, triage, ultrasound-guided diagnosis); dedicated comorbidity specialists; enhanced communication with primary care (hotline, education sessions); and integrating patient registries into daily clinical practice. CONCLUSION: Learning from implementation of good practice interventions in centres across Europe provides an opportunity to more widely improved care for patients with RA and associated comorbidities.

Centre for Musculoskeletal Research School of Biological Sciences University of Manchester Manchester UK

Cliniques Universitaires Saint Luc UCL Brussels Belgium

Copenhagen Center for Arthritis Research Center for Rheumatology and Spine Diseases Rigshospitalet Kobenhavn Denmark

Department of Internal Medicine Specialties University Hospitals of Geneva Geneva Switzerland

Department of Respiratory Medicine and Allergy Karolinska University Hospital Solna Karolinska Institutet Stockholm Sweden

Dept of Rheumatology Diakonhjemmet Hospital Oslo Norway

Global Strategy Group KPMG LLP London UK

Hôpital Cochin Rheumatology Université Paris Descartes Paris France

Hospital De Santa Maria Lisboa Portugal

Hospital Universitario La Paz Madrid Spain

Leeds Institute of Rheumatic and Musculoskeletal Medicine Chapel Allerton Hospital Leeds UK

Neil Betteridge Associates London UK

Radboud University Medical Center Nijmegen Nijmegen Netherlands

Respiratory Medicine Unit Department of Medicine Solna and Center for Molecular Medicine Karolinska Institutet Stockholm Sweden

Rheumatologic Clinic Institute of Rheumatology Prague Czech Republic

Rheumatology Gaetano Pini Institute Milan Italy

Rheumatology Karolinska Institutet Stockholm Sweden

Salisbury NHS Foundation Trust Salisbury UK

Sint Maartenskliniek Nijmegen Netherlands

University of Cologne Koln Germany

Utrecht University Utrecht Netherlands

Komentář v

Nat Rev Rheumatol. 2020 Nov;16(11):607-608. doi: 10.1038/s41584-020-00504-y. PubMed

Zobrazit více v PubMed

Song L, Yangsheng Y, Yinshi Y, et al. Microbial infection and rheumatoid arthritis. J Clin Cell Immunol 2013;174 10.4172/2155-9899.1000174 PubMed DOI PMC

Angel J, Akesson K, Amadio PC, et al. The burden of musculoskeletal conditions at the start of the new millennium. World Health Organization 2003;919:1–218. PubMed

Norton S, Carpenter L, Nikiphorou E, et al. Excess mortality in rheumatoid arthritis: gains in life expectancy over 25 years. Rheumatology Abstract O34 2014;53:i43–i44. 10.1093/rheumatology/keu091.004 DOI

Dougados M, Soubrier M, Antunez A, et al. Prevalence of comorbidities in rheumatoid arthritis and evaluation of their monitoring: results of an international, cross-sectional study (COMORA). Ann Rheum Dis 2014;73:62–8. 10.1136/annrheumdis-2013-204223 PubMed DOI PMC

Radner H, Yoshida K, Smolen J, et al. Multimorbidity and rheumatic conditions - enhancing the concept of comorbidity. Nat Rev Rheumatol 2014;10:252–6. 10.1038/nrrheum.2013.212 PubMed DOI

Holmqvist M, Ljung L, Askling J. Acute coronary syndrome in new-onset rheumatoid arthritis: a population-based nationwide cohort study of time trends in risks and excess risks. Ann Rheum Dis 2017;76:1642–7. 10.1136/annrheumdis-2016-211066 PubMed DOI

Bongartz T, Nannini C, Medina-Velasquez Y, et al. Incidence and mortality of interstitial lung disease in rheumatoid arthritis: a population-based study. Arthritis Rheum 2010;62:1583–91. 10.1002/art.27405 PubMed DOI PMC

Solomon DH, Love TJ, Canning C, et al. Risk of diabetes among patients with rheumatoid arthritis, psoriatic arthritis and psoriasis. Ann Rheum Dis 2010;69:2114–7. 10.1136/ard.2009.125476 PubMed DOI PMC

Sheehy C, Murphy E, Barry M. Depression in rheumatoid arthritis: underscoring the problem. Rheumatology 2006;45:1325–7. 10.1093/rheumatology/kel231 PubMed DOI

Matcham F, Rayner L, Steer S, et al. The prevalence of depression in rheumatoid arthritis: a systematic review and meta-analysis. Rheumatology (Oxford) 2013;52:2136–48. 10.1093/rheumatology/ket169 PubMed DOI PMC

Cross M, Smith E, Hoy D, et al. The global burden of rheumatoid arthritis: estimates from the global burden of disease 2010 study. Ann Rheum Dis 2014;73:1316–22. 10.1136/annrheumdis-2013-204627 PubMed DOI

Baillet A, Gossec L, Carmona L, et al. Points to consider for reporting, screening for and preventing selected comorbidities in chronic inflammatory rheumatic diseases in daily practice: a EULAR initiative. Ann Rheum Dis 2016;75:965–73. 10.1136/annrheumdis-2016-209233 PubMed DOI

Winthrop K, Weinblatt M, Crow M, et al. Unmet need in rheumatology: reports from the targeted therapies meeting 2018. Ann Rheum Dis 2019;78:872–8. 10.1136/annrheumdis-2018-214280 PubMed DOI

Bosworth A, Hancock T, Hewitt J, et al. Breaking down barriers: rheumatoid arthritis and public awareness. National Rheumatoid Arthritis Society (NRAS), 2013: 1–39.

Stack R, Nightingale P, Jinks C, et al. Delays between the onset of symptoms and first rheumatology consultation in patients with rheumatoid arthritis in the UK: an observational study. BMJ Open 2019;9:e024361 10.1136/bmjopen-2018-024361 PubMed DOI PMC

Aletaha D, Neogi T, Silman AJ, et al. Rheumatoid arthritis classification criteria: an American College of Rheumatology/European League Against Rheumatism collaborative initiative. Ann Rheum Dis 2010;69:1580–8. 10.1136/ard.2010.138461 PubMed DOI

National Rheumatoid Arthritis Society (NRAS) Keep taking the pills: the critical importance of adherence in the management of rheumatoid arthritis. 2018.

Hider SL, Blagojevic-Bucknall M, Whittle R, et al. What does a primary care annual review for RA include? A national GP survey. Clin Rheumatol 2016;35:2137–8. 10.1007/s10067-015-3093-9 PubMed DOI

National Rheumatoid Arthritis Society (NRAS) Rheumatology in Wales, the state of play, 2016.

UK Parliament Early identification and diagnosis of rheumatoid arthritis. 2010.

Garneau KL, Iversen MD, Tsao H, et al. Primary care physicians’ perspectives towards managing rheumatoid arthritis: room for improvement. Arthritis Res Ther 2011;13:R189 10.1186/ar3517 PubMed DOI PMC

Miltenburger C, Karampampa K, Richard BT, et al. A survey of barriers to treatment access in rheumatoid arthritis. I3 Innovus 2009;5:1–29.

Marengo M, Suarez-Almazor M. Improving treatment adherence in patients with rheumatoid arthritis: what are the options. Int J Clin Rheumatol 2015;10:345–56. 10.2217/ijr.15.39 PubMed DOI PMC

National Rheumatoid Arthritis Society (NRAS) The impact of rheumatoid arthritis comorbidities. 2012: 1–29.

Peters MJL, Symmons DPM, McCarey D, et al. EULAR evidence-based recommendations for cardiovascular risk management in patients with rheumatoid arthritis and other forms of inflammatory arthritis. Ann Rheum Dis 2010;69:325–31. 10.1136/ard.2009.113696 PubMed DOI

Bartels CM, Saucier JM, Thorpe CT, et al. Monitoring diabetes in patients with and without rheumatoid arthritis: a medicare study. Arthritis Res Ther 2012;14:1–9. 10.1186/ar3915 PubMed DOI PMC

Selmi C, Santis M, Gershwin M. Liver involvement in subjects with rheumatic disease. Arthritis Res Ther 2011;13:226 10.1186/ar3319 PubMed DOI PMC

Corrales A, González-Juanatey C, Peiró ME, et al. Carotid ultrasound is useful for the cardiovascular risk stratification of patients with rheumatoid arthritis: results of a population-based study. Ann Rheum Dis 2014;73:722–7. 10.1136/annrheumdis-2012-203101 PubMed DOI

Nakajima A, Inoue E, Shimizu Y, et al. Presence of comorbidity affects both treatment strategies and outcomes in disease activity, physical function, and quality of life in patients with rheumatoid arthritis. Clin Rheumatol 2015;34:441–9. 10.1007/s10067-014-2750-8 PubMed DOI

Agca R, Heslinga S, Rollefstad S, et al. EULAR recommendations for cardiovascular disease risk management in patients with rheumatoid arthritis and other forms of inflammatory joint disorders: 2015/2016 update. Ann Rheum Dis 2017;76:17–28. 10.1002/1529-0131(200003)43:3<522::AID-ANR7>3.0.CO;2-Y PubMed DOI

Mach F, Baigent C, Catapano A, et al. European Society of Cardiology/European Atherosclerosis Society Guidelines for the management of dyslipidaemias: lipid modification to reduce cardiovascular risk. Eur Heart J 2019;00:1–78. 10.1136/annrheumdis-2016-209775 PubMed DOI

Andreu Sanchez JL, Balsa A, Gualda E, et al. Update of the clinical practice guideline for the management of rheumatoid arthritis in Spain. Spanish Soc Rheumatol 2011.

André-Vert J, Guillez P, Scémama O. Clinical practice guidelines: rheumatoid arthritis - medical, social and organisational aspects of treatment (excluding surgery and drugs). Haute Autorite De Sante, 2017.

Raghu G, Remy-Jardin M, Myerset J, et al. Diagnosis of idiopathic pulmonary fibrosis. An official ATS/ERS/JRS/ALAT clinical practice guideline. Am J Respir Crit Care Med 2018;198:44–68. PubMed

Skold M. Idiopatisk Lungfibros, Vårdprogram. Swedish Respiratory Society, 2019. 10.1164/rccm.201807-1255ST DOI

Pilling S, Anderson I, Goldberg D, et al. Depression in adults with a chronic physical health problem: recognition and management. NICE 2009. PubMed PMC

Smolen JS, Landewé R, Bijlsma J, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2016 update. Ann Rheum Dis 2017;76:960–77. 10.1002/acr.22812 PubMed DOI

Villeneuve E, Nam JL, Bell MJ, et al. A systematic literature review of strategies promoting early referral and reducing delays in the diagnosis and management of inflammatory arthritis. Ann Rheum Dis 2013;72:13–22. 10.1136/annrheumdis-2016-210715 PubMed DOI

Dixon WG, Hyrich KL, Watson KD, et al. Influence of anti-TNF therapy on mortality in patients with rheumatoid arthritis-associated interstitial lung disease: results from the British Society for Rheumatology Biologics Register. Ann Rheum Dis 2010;69:1086–91. 10.1136/annrheumdis-2011-201063 PubMed DOI PMC

Radner H, Chatzidionysiou K, Nikiphorou E, et al. 2017 EULAR recommendations for a core data set to support observational research and clinical care in rheumatoid arthritis. Ann Rheum Dis 2018;77:476–9.10.1136/ard.2009.120626 PubMed DOI

Eriksson J, Askling J, Arkema E. The Swedish rheumatology quality register: optimisation of rheumatic disease assessments using register-enriched data. Clin Exp Rheumatol 2014;32:S147–9. 10.1136/annrheumdis-2017-212256 PubMed DOI

Doyle C, Lennox L, Bell D. A systematic review of evidence on the links between patient experience and clinical safety and effectiveness. BMJ Open 2013;3:1–18. PubMed PMC

Vare P, Nikiphorou E, Hannonen P, et al. Delivering a one-stop, integrated, and patient-centered service for patients with rheumatic diseases. SAGE Open Med 2016;4:2050312116654404 10.1136/bmjopen-2012-001570 PubMed DOI PMC

Arts EE, Popa C, Den Broeder AA, et al. Performance of four current risk algorithms in predicting cardiovascular events in patients with early rheumatoid arthritis. Ann Rheum Dis 2015;74:668–74. 10.1177/2050312116654404 PubMed DOI

Crowson C, Matteson EL, Roger VL, et al. Usefulness of risk scores to estimate the risk of cardiovascular disease in patients with rheumatoid arthritis. Am J Cardiol 2012;110:420–4. 10.1136/annrheumdis-2013-204024 PubMed DOI PMC

Ørstavik RE, Haugeberg G, Mowinckel P, et al. Vertebral deformities in rheumatoid arthritis: a comparison with population-based controls. Arch Intern Med 2004;23:420–5. 10.1016/j.amjcard.2012.03.044 PubMed DOI

Semb AG, Ikdahl E, Hisdal J, et al. Exploring cardiovascular disease risk evaluation in patients with inflammatory joint diseases. Int J Cardiol 2016;223:331–6. 10.1001/archinte.164.4.420 PubMed DOI

Rollefstad S, Kvien TK, Holme I, et al. Treatment to lipid targets in patients with inflammatory joint diseases in a preventive cardio-rheuma clinic. Ann Rheum Dis 2013;72:1968–74. 10.1016/j.ijcard.2016.08.129 PubMed DOI

Rollefstad S, Ikdahl E, Hisdal J, et al. Systemic inflammation in patients with inflammatory joint diseases does not influence statin dose needed to obtain LDL cholesterol goal in cardiovascular prevention. Ann Rheum Dis 2015;74:1544–50. 10.1136/annrheumdis-2012-202789 PubMed DOI

Otsuka Y, Kiyohara C, Kashiwado Y, et al. Effects of tumor necrosis factor inhibitors and tocilizumab on the glycosylated hemoglobin levels in patients with rheumatoid arthritis; an observational study. PLoS One 2018;13:e0196368 10.1136/annrheumdis-2013-204636 PubMed DOI PMC

Haugeberg G, Uhlig T, Falch JA, et al. Bone mineral density and frequency of osteoporosis in female patients with rheumatoid arthritis: results from 394 patients in the Oslo County Rheumatoid Arthritis register. Arthritis Rheum 2000;43:522–30. 10.1371/journal.pone.0196368 PubMed DOI

Haugeberg G, Uhlig T, Falch JA, et al. Reduced bone mineral density in male rheumatoid arthritis patients: frequencies and associations with demographic and disease variables in ninety-four patients in the Oslo County Rheumatoid Arthritis Register. Arthritis Rheum 2000;43:2776–84. 10.1002/1529-0131(200012)43:12<2776::AID-ANR18>3.0.CO;2-N PubMed DOI

Ørstavik RE, Haugeberg G, Uhlig T, et al. Self-reported non-vertebral fractures in rheumatoid arthritis and population based controls: incidence and relationship with bone mineral density and clinical variables. Ann Rheum Dis 2004;63:177–82. 10.1136/ard.2003.005850 PubMed DOI PMC

Furer V, Rondaan C, Heijstek M, et al. 2019 update of EULAR recommendations for vaccination in adult patients with autoimmune inflammatory rheumatic diseases. Ann Rheum Dis 2020;79:39–52. 10.1136/annrheumdis-2019-215882 PubMed DOI

Winthrop L. Update on tuberculosis and other opportunistic infections associated with drugs blocking tumour necrosis factor α. Ann Rheum Dis 2005;64:29–30. 10.1136/ard.2005.042390 PubMed DOI PMC

Rodríguez-Lozano B, González-Febles J, Garnier-Rodríguez J, et al. Association between severity of periodontitis and clinical activity in rheumatoid arthritis patients: a case: control study. Arthritis Res Ther 2019;21:27 10.1186/s13075-019-1808-z PubMed DOI PMC

Nayak P, Luo R, Elting L, et al. Impact of rheumatoid arthritis on the mortality of elderly patients who develop cancer: a population-based study. Arthritis Care Res 2017;69:75–83. 10.1002/acr.22997 PubMed DOI

Van den Hoek J, Boshuizen HC, Roorda LD, et al. Association of somatic comorbidities and comorbid depression with mortality in patients with rheumatoid arthritis: a 14-year prospective cohort study. Arthritis Care Res 2016;68:1055–60. PubMed