Musculoskeletal practice guidelines for general practitioners

New evidence-based musculoskeletal disease prevention and treatment guidelines for general practitioners have been issued by the Royal Australian College of General Practitioners (RACGP). Rheumatoid arthritis (RA), juvenile idiopathic arthritis, and osteoarthritis guidelines have been released, and osteoporosis guidelines were expected to be available soon.

The new guidelines are significant, according to the RACGP, because most current clinical guidelines are consensus-based rather than evidence-based. Each guideline includes diagnosis and management algorithms designed to be used as reference tools during consultations. The recommendations provide a summary and grading of the available evidence. The focus is on early diagnosis and management to provide treatment that effectively limits structural damage and improves health outcomes.

In developing the guidelines, the RACGP collaborated with expert working groups and the National Health Medical Research Council (NHMRC). They are among the first guidelines to use the NHMRC Evidence-based Matrix, which provided additional levels of evidence and gradings of recommendations, and already are attracting significant international interest, the RACGP noted.

RACGP recommendations for general practitioners in the treatment of patients who have RA include the following:
•Make the diagnosis of RA as early as possible to optimize outcomes. If there is persistent swelling after 6 weeks, even if the diagnosis of RA is not confirmed, refer patients to a rheumatologist.
•Initially base a diagnosis of RA (and the differential diagnosis) on the clinical examination (a strong suspicion of RA is indicated by the presence of persistent joint pain and swelling affecting at least 3 joint areas, symmetrical involvement of the metacarpophalangeal or metatarsophalangeal joints, or morning stiffness lasting more than 30 minutes).
•For patients who present with painful and swollen joints, support the clinical examination with appropriate testing (eg, erythrocyte sedimentation rate, C-reactive protein level, rheumatoid factor, anticyclic citrullinated peptide antibody level) to exclude other forms of arthritis and other differential diagnoses and to predict which patients probably will progress to erosive disease.
•Encourage and support a management approach based on individual patient need and involvement of a multidisciplinary team of health professionals. Try to engage patients with RA in individualized care plans that include treatment goals and objective measures of disease.
•Provide ongoing, tailored information to support patients' understanding of their disease, treatment options, possible outcomes, and role in self-management. Encourage patients to seek appropriate information from relevant support agencies and to participate in appropriate formal education opportunities according to their specific needs.
•Ensure access to appropriate psychosocial support for patients with RA, including support in managing relationship and sexuality issues; assess and manage sleep quality for patients with RA; and consider the use of behavioral therapy, exercise, and tricyclic agents for early management of sleep disturbances.
•When possible, consider using simple analgesics for pain relief in early arthritis. Recommend omega-3 fatty acid supplementation as an adjunct for management of pain and stiffness in patients with RA.
•When simple analgesia and omega-3 fatty acids are ineffective, consider using conventional NSAIDs or selective cyclooxygenase-2 (COX-2) inhibitors for reducing pain and stiffness in the short-term treatment of patients with RA.
•Exercise caution when using traditional NSAIDs and COX-2 inhibitors, especially in patients at particular risk, such as older patients and those who have GI, renal, or cardiovascular comorbidities. Base the choice of NSAIDs or COX-2 inhibitors on consideration of the patient's specific needs, baseline risk profile, and concomitant medications, weighing the potential benefits against potential harms.
•Facilitate early treatment with disease-modifying antirheumatic drugs (DMARDs) for patients who have a diagnosis of RA and those patients with undifferentiated inflammatory arthritis who are judged to be at risk for persistent or erosive arthritis or both. Because of the potential toxicity of these agents, it is recommended that DMARD therapy be initiated by a rheumatologist. If DMARD therapy is used, choose methotrexate as first-line treatment, particularly when the disease is judged to be moderate to severe or there is a high risk of erosive disease.
•When simple analgesics, omega-3 fatty acids, and NSAIDs or COX-2 inhibitors have not achieved symptomatic relief, consider undertaking short-term, low-dose, oral corticosteroid treatment in consultation with a rheumatologist and with consideration of the patient's comorbidities and individual risk factors. Consider intra-articular corticosteroid injections for rapid symptomatic relief of inflammation in target joints (no more than 3 injections per year for a specific joint).
•Inform patients about complementary and alternative medicines, the insufficient volume of evidence available on their use in managing RA, and their potential adverse effects and interactions.
•For all patients with RA, encourage dietary modification and weight control and, to maintain strength and physical functioning, regular dynamic physical activity compatible with their general abilities.
•Support patients' access to appropriate foot care.

For more information about the RA and other musculoskeletal guidelines or to download them (at no cost), visit the RACGP Web site at http://www.racgp.org.au/guidelines. Or, contact the organization at Royal Australian College of General Practitioners, 1 Palmerston Crescent, South Melbourne, Vic 3205, Australia; telephone: +61 (3) 8699 0414; fax : +61 (3) 8699 0400.