Musculoskeletal

Rheumatoid Arthritis

A systemic inflammatory synovitis that can irreversibly damage joints and organs; refer persistent synovitis urgently and start specialist-led treat-to-target DMARD therapy early.

In a nutshell

Persistent inflammatory synovitis needs early rheumatology assessment even when CRP and serology are normal. NICE recommends cDMARD monotherapy as soon as possible, ideally within 3 months of persistent symptoms, then treat-to-target monitoring for remission or low disease activity. Escalate sequentially or in combination, use specialist biologic/targeted synthetic options after inadequate intensive cDMARD therapy, and maintain DMARD safety monitoring and flare access.

Classic presentation

Weeks of symmetrical MCP, PIP, wrist or MTP pain and soft swelling with morning stiffness over 30 minutes that improves with movement, fatigue and functional decline; serology may be positive or negative.

Key points

Refer persistent synovitis of undetermined cause; refer urgently when small hand/foot joints or more than one joint is affected, or symptoms have been present for 3 months or more, even if CRP and RF/anti-CCP are negative.
Offer rheumatoid factor with synovitis, consider anti-CCP if RF is negative, and X-ray hands and feet; investigations must not delay referral.
After diagnosis, establish anti-CCP, erosions and baseline function; anti-CCP positivity or erosions increase radiological-progression risk.
Start oral methotrexate, leflunomide or sulfasalazine monotherapy as soon as possible and ideally within 3 months of persistent symptoms; consider hydroxychloroquine for mild or palindromic disease.
Use short-term glucocorticoids selectively as a bridge or for flares; avoid routine long-term steroid dependence.
Treat to remission or low disease activity, measuring CRP and a composite score such as DAS28 monthly in active specialist-managed disease until target.
If target is not reached after dose escalation, add cDMARDs in combination; specialist biologic or targeted synthetic DMARDs follow intensive cDMARD therapy under current NICE technology appraisals.
Monitor csDMARD toxicity with current BSR risk-stratified blood-test schedules and use a multidisciplinary team, annual review and rapid flare access.

First-line investigation

Clinical assessment for persistent synovitis with RF, anti-CCP when appropriate, CRP/ESR and hand/foot radiographs; never delay rheumatology referral for test results.

Management

Recognise synovitis and refer

Refer persistent synovitis of undetermined cause to rheumatology; make the referral urgent for small-joint, polyarticular or 3-month-delayed presentations regardless of normal CRP or negative serology.²
Check for infection, crystal arthritis, cervical-spine symptoms, eye/lung/vascular disease and the functional impact while arranging referral.^2,1

Confirm risk and start the first DMARD

Use RF, anti-CCP when appropriate, CRP/ESR, hand/foot radiographs and baseline function without delaying specialist review.²
Start oral methotrexate, leflunomide or sulfasalazine monotherapy as soon as possible and ideally within 3 months of persistent symptoms; consider hydroxychloroquine for mild or palindromic disease.^2,7,8,9,11

Bridge symptoms and protect function

Consider short-term glucocorticoid bridging when starting a new DMARD and offer short-term treatment for flares; avoid unreviewed long-term steroid use.^2,12
Use physiotherapy, occupational therapy, podiatry, hand exercise, psychological support and self-management education according to functional need.^2,10

Treat to target and escalate safely

Measure CRP and a composite activity score such as DAS28 monthly in active specialist care until remission or low disease activity is achieved; add cDMARDs in combination if target is not reached after dose escalation.^2,5
After inadequate intensive therapy with at least 2 cDMARDs in combination, use the current NICE technology-appraisal pathway for a biological or targeted synthetic DMARD, usually with methotrexate unless unsuitable.^2,5

Monitor medicines, complications and access

Follow current BSR csDMARD blood monitoring: assess toxicity risk, check FBC/renal/liver/albumin at week 2 and monthly during induction for people without risk factors, then at least 3-monthly when stable with risk-tailored adjustments.^6,7,8,9
Provide rapid flare access, review around 6 months after target, perform annual disease/function/comorbidity/complication review, and consider step-down only after at least 1 year at target without glucocorticoids.²

Exam traps

Negative RF, anti-CCP or CRP does not exclude RA and must not delay urgent referral for persistent synovitis.
Do not wait for erosions on X-ray before referring or starting disease-modifying treatment.
A biologic or targeted synthetic DMARD is not the initial primary-care treatment; it follows specialist assessment and inadequate intensive cDMARD therapy under current NICE appraisals.
Long-term glucocorticoids are not a substitute for DMARD optimisation; use short-term bridging or flare treatment selectively.
A hot swollen joint in a person with RA may be septic arthritis, especially with immunosuppression or a prosthesis; treat it as an urgent separate problem.
Neck symptoms with neurological signs may indicate cervical myelopathy and require urgent MRI and surgical opinion.

Illustrations

Ulnar deviation and MCP swelling in rheumatoid arthritisRheumatoid arthritis of the hand with small-joint swelling and ulnar deviation, illustrating chronic inflammatory joint damage.James Heilman, MD, Wikimedia Commons · CC-BY-SA-3.0

Radiographic erosions in rheumatoid arthritisHand radiograph showing peri-articular osteopenia and marginal erosions that may occur in established rheumatoid arthritis.Bernd Braegelmann (Braegel), Wikimedia Commons · CC-BY-3.0

Synovitis and joint erosionDiagram of inflammatory synovium extending into cartilage and juxta-articular bone, illustrating how persistent synovitis can cause erosive damage.PassFinals · original

Key sources

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.