Diagnosis

• Recent onset: < 2 yrs
• Clinical diagnosis accepted over American Rheumatism Association guidelines 1987
• Refer urgently if any of the following apply:
  • Small joints of the hands or feet are affected
  • More than one joint is affected
  • Delay of 3 months or longer between onset of symptoms and seeking medical advice

Investigation

• Rheumatoid factor blood test if suspect RA and have synovitis on clinical examination
• Anti-cyclic citrullinated peptide (CCP) Ab if suspected RA and:
  • Negative for rheumatoid factor, and
  • Need to inform decision-making about starting combination therapy
• X-ray hands and feet early in people with persistent synovitis in these joints
• CRP measured regularly, and key components of disease activity (e.g. DAS28) to inform decision-making in:
  • Increasing treatment to control disease
  • Cautiously decreasing treatment when disease is controlled

Management

Conservative:

• MDT
  • Specialist nurse: access
  • Physiotherapist: improve fitness, encourage regular exercise, exercises for enhancing joint flexibility, muscle strength
  • Occupational therapist: with ADLs and hand function
  • Podiatrist: foot problems, offering functioning insoles and therapeutic footwear
  • Psychological: stress, coping skills
• Diet: no evidence for complimentary therapy but Mediterranean diet beneficial

Pharmacological Therapy

• Newly diagnosed RA:
• First Line: combination DMARDs (Methotrexate + min 1 other DMARD + short-term glucocorticoids
• If disease control achieved, cautiously reduce dose
• If combination not appropriate: DMARD monotherapy, escalating to a clinically effective dose
• If introducing new drugs consider stopping / reducing existing drug once disease controlled
• Managing flares: short-term glucocorticoids with recent-onset or established disease

Biologics

• Section 2: for Biologics technology appraisal
• Anakinra is not recommended not in combination with Anti-TNF

Symptom Control:

• Analgesia
• Paracetamol regularly for pain relief in addition to core treatments
• NSAID (topical) for pain relief in addition to core treatments with knee or hand osteoarthritis
• NSAID/COX-2 inhibitor if non selective NSAID/Paracet ineffective, lowest dose shortest duration
• NSAID/COX-2 inhibitor: varying gastrointestinal, liver and cardio-renal toxicity
• If above analgesics not providing control, review DMARDs

Surgery Referral

• Persistent pain due to joint damage or other identifiable soft tissue cause
• Worsening joint function
• Progressive deformity
• Persistent localised synovitis
• Imminent or actual tendon rupture
• Nerve compression (for example, carpal tunnel syndrome)
• Stress fracture.

NICE Source: CG79 Rheumatoid arthritis in adults: management. Summary compiled by Dr D P Sheppard MBBS.