Management of early rheumatoid arthritis with disease modifying anti-rheumatic drugs: guidelines, current practice and the role of community pharmacy

  • Sarah Wood

Student thesis: Phd


Abstract Background: Despite increasing evidence for the optimal pharmacological management of early rheumatoid arthritis (RA), there remains uncertainty concerning the most effective treatment regimen and in particular the role of combination disease modifying anti-rheumatic drug (DMARDs) in early disease. Optimising medicines use will contribute to their effectiveness and community pharmacists (CP) are well placed to support this. However, little is known about the role CP play in managing RA. Aims: 1) Investigate DMARD utilisation in early RA and outcomes associated with various treatment approaches; 2) Explore the current role of community pharmacists in RA management. Methods: Data from the Rheumatoid Arthritis Medication Study (RAMS, 2008 to 2019), a large UK prospective study recruiting patients starting methotrexate (MTX) for the first time, were used in this thesis and included information on demographics, disease activity, and RA treatments captured at MTX start, and at 6 and 12 months thereafter. Patients were categorised as starting (1) MTX monotherapy or (2) MTX/other DMARD combination therapy. Patient characteristics at treatment start and outcomes after 6 months were compared. In parallel, a mixed methods study including a survey of UK based CP (n=84) and semi-structured interviews (n=9) was conducted. The survey was analysed using content analysis and simple proportions and thematic analysis was used to identify the key themes from the interviews. Results: Overall, most patients started MTX monotherapy (n=878, 72%), despite national guidelines recommending combination therapy. Hydroxychloroquine (HCQ) was used with MTX in most instances of combination therapy. Younger age, higher physician disease severity rating, and lower MTX dose were associated with use of combination therapy over monotherapy; however, there was no association between initial treatment regimen and outcome at 6 months. In general, the CP survey found almost half rated their RA knowledge as good and provided counselling on MTX, largely focussing on safety, but less commonly on other DMARDs such as HCQ. Many barriers to increasing their role in RA management were found in interviews (e.g. lack of information, lack of funding, and prioritising more common conditions) but most felt confident with to provide MURs despite lack of RA knowledge. Conclusion: Rheumatologists did not follow national guidance for pharmacological management of early RA, but there was no difference in outcomes when they did, suggesting no advantage to more complex treatment regimens, which has implications for guideline developers and policy makers. There is a clear current role that CP play in the pharmacological management of RA however, this is focused on side-effect counselling and reducing practical barriers to taking medicines. There may be significant barriers to both the current and future role of CP in the management of RA and these include: a lack of access to clinical information, a perceived lack of knowledge and the fact that pharmacists perceive patients with RA to be a low priority compared to patients with other long-term conditions, but this research has highlighted a potential future and even expanded role for CP in supporting people with RA, if these barriers can be addressed.
Date of Award31 Dec 2021
Original languageEnglish
Awarding Institution
  • The University of Manchester
SupervisorKimme Hyrich (Supervisor), Suzanne Verstappen (Supervisor) & Douglas Steinke (Supervisor)


  • methotrexate
  • community
  • pharmacist
  • rheumatoid

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