The National Institute for Health and Clinical Excellence (NICE), in association with the Royal College of Physicians (RCP) have issued clinical guidelines for the management of patients with rheumatoid arthritis (RA).

With respect to pharmacological management, the guidelines make recommendations for the use of disease modifying antirheumatic drugs (DMARDs), introducing DMARDs, optimal sequencing of DMARDs, and when to withdraw them. The recommendations have been outlined below (all taken directly from source).

NICE makes the following recommendations for early introduction and optimal sequencing of DMARDs:
• In people with newly diagnosed active RA, offer a combination of DMARDs (including methotrexate and at least one other DMARD, plus short-term glucocorticoids) as first-line treatment as soon as possible, ideally within 3 months of the onset of persistent symptoms.
• In people with recent-onset RA receiving combination DMARD therapy and in whom sustained and satisfactory levels of disease control have been achieved, cautiously try to reduce drug doses to levels that still maintain disease control.
• In people with newly diagnosed RA for whom combination DMARD therapy is not appropriate, start DMARD monotherapy, placing greater emphasis on fast escalation to a clinically effective dose rather than on the choice of DMARD.

NICE makes the following recommendations for the withdrawal of DMARDS or biological drugs:
• In people with established RA whose disease is stable, cautiously reduce dosages of disease modifying or biological drugs. Return promptly to disease-controlling dosages at the first sign of a flare.
• When introducing new drugs to improve disease control into the treatment regimen of a person with established RA, consider decreasing or stopping their pre-existing rheumatological drugs once the disease is controlled.
• In any person with established rheumatoid arthritis in whom disease-modifying or biological drug doses are being decreased or stopped, arrangements should be in place for prompt review.

NICE makes the following recommendations for the use of glucocorticoids for rheumatoid arthritis:
• Consider offering short-term treatment with glucocorticoids (oral, intramuscular or intraarticular) to rapidly improve symptoms in people with newly diagnosed RA if they are not already receiving glucocorticoids as part of DMARD combination therapy.
• Offer short-term treatment with glucocorticoids for managing flares in people with recent onset or established disease, to rapidly decrease inflammation.
• In people with established RA, only continue long-term treatment with glucocorticoids when:
- the long-term complications of glucocorticoid therapy have been fully discussed, and
- all other treatment options (including biological drugs) have been offered.

With respect to the use of biological agents, NICE refers to the respective technology appraisals for:
• rituximab for refractory rheumatoid arthritis
• abatacept for refractory rheumatoid arthritis
• Adalimumab, etanercept and infliximab for the treatment of rheumatoid arthritis

Additionally, the guidelines state that the available data does not answer the clinical question of whether a patient who is not responding to DMARD therapy should go onto other conventional DMARDs or onto a biological drug.

The guidelines also state that on the balance of its clinical benefits and cost effectiveness, anakinra is not recommended for the treatment of RA, except in the context of a controlled, long-term clinical study. Patients currently receiving anakinra for RA may suffer loss of wellbeing if their treatment were discontinued at a time they did not anticipate. Therefore, patients should continue
therapy with anakinra until they and their consultant consider it is appropriate to stop. The combination of tumour necrosis factor- (TNF) inhibitor therapy and anakinra for RA should not be offered.

The guidelines make the following recommendations for symptom control:
• Offer analgesics (for example, paracetamol, codeine or compound analgesics) to people with RA whose pain control is not adequate, to potentially reduce their need for long-term treatment with non-steroidal anti-inflammatory drugs (NSAIDs) or cyclo-oxygenase-2 (COX-2) inhibitors.
• Oral NSAIDs/Cox-2 inhibitors should be used at the lowest effective dose for the shortest possible period of time.
• When offering treatment with an oral NSAID/Cox-2 inhibitor, the first choice should be either a standard NSAID or a COX-2 inhibitor (other than etoricoxib 60 mg). In either case, these should be coprescribed with a PPI, choosing the one with the lowest acquisition cost.
• All oral NSAIDs/COX-2 inhibitors have analgesic effects of a similar magnitude but vary in their potential gastrointestinal, liver and cardio-renal toxicity; therefore, when choosing the agent and dose, healthcare professionals should take into account individual patient risk factors, including age. When prescribing these drugs, consideration should be given to appropriate assessment and/or ongoing monitoring of these risk factors.
• If a person with RA needs to take low-dose aspirin, healthcare professionals should consider other analgesics before substituting or adding an NSAID or COX-2 inhibitor (with a PPI) if pain relief is ineffective or insufficient.
• If NSAIDs or COX-2 inhibitors are not providing satisfactory symptom control, review the disease-modifying or biological drug regimen.

Please see link below for the full guideline.