The management of rheumatoid arthritis (RA) has changed dramatically over the past two decades. But there remains substantial variability both around the world as to how and when drugs are prescribed, and there are areas where improved guidelines and a more collaborative approach may help improve care even further.

“There is no doubt that RA has dramatically changed in how it is managed nowadays since 20, 30 years ago,” said Dr David Scott, of the Centre for Rheumatic Diseases at King’s College London, in an interview with the limbic. “And actually the outcomes have gotten better.”

Dr Scott co-wrote an editorial in The Journal of Rheumatology along with Drs Elena Nikiphorou and Fowzia Ibrahim on some of those changes over time. In it, he notes that national and international RA guidelines emphasise the prompt treatment of active RA with conventional disease-modifying antirheumatic drugs (cDMARDs), before moving on to biologic and targeted synthetic DMARDs in patients with incomplete responses.

Reassuringly, data suggests management of RA has increasingly followed those guidelines as years have past. A study in the same journal, conducted in Nova Scotia in Canada, prescribing of both cDMARDs and biologics increased, while prescribing of NSAIDs declined.

A remaining concern, though, is the use of steroids. In that study, over the 20-year period the proportion of patients with a corticosteroid prescription remained largely unchanged. An English study from several years ago found that three-quarters of a cohort of 7,000 early RA patients received steroids.

“Steroids are good in the short term, but they have all sorts of long-term problems,” Dr Scott said, adding that there is some possibility that poorer outcomes in RA seen decades ago may have been at least partially a result of over-treatment with steroids.

What some of these studies reveal is that in spite of increases in DMARD use over time, there is still substantial deviation from published guidelines on RA management. Dr Scott, who has been involved with guideline development since 1990, said there is no doubt that some guidelines have had positive effects on patient care, but they remain a complicated, and often political process. His editorial also noted that guideline development for RA has often had minimal involvement from other specialties beyond rheumatology or from generalists, though it is often generalists that first need to identify a patient with early RA.

The COVID-19 pandemic has also hindered the progress on RA management, partially due to the suspension of the England’s national audit of early arthritis.

“The whole of care got mangled up in the last year,” Dr Scott said. The audit, he said, has undoubtedly helped set up better early-RA pathways of care. “I think it’s had a very positive effect.”

The pandemic does present opportunities for improving care in the future as well. Because many clinics were forced to turn to digital/remote consultations, Dr Scott and his colleagues wrote that there may be opportunities to harness the new glut of digital clinical data. “This area appears ripe for new initiatives.”