Guidelines

Referral Criteria

Refer for specialist opinion in any adult with synovitis of undetermined cause.

Refer urgently if ANY of the following (even if normal acute phase reactant and -ve antibodies):

• Small joints of the hands or feet are affected
• >1 joint affected
• Delay of ≥3 months between symptom onset and seeking medical advice

Investigation and Diagnosis

Do not delay referral by ordering the following investigations. In primary care the top priority is referral.

1st line tests:

• Rheumatoid factor, and
• X-ray of the hand and feet

If rheumatoid factor is -ve → consider measuring anti-CCP antibodies

• If a diagnosis of RA is made, make sure to measure anti-CCP antibodies, if not already done

Management

Treatment target in active RA is:

• Complete remission, or
• Low disease activity (treat-to-target), if remission not possible

Flare Management

Offer short-term glucocorticoid therapy to manage flares.

Not stated in NICE, but standard practice for choosing the route of steroid administration:^{[Ref1][Ref 2]}

• Localised (mono- or oligoarticular)
  • Intra-articular
• Non-localized (polyarticular) disease
  • Intramuscular (typically single injection) OR
  • Oral (typically short, 2-4 week, reducing dose regimen)

Long-Term Pharmacological Management

In addition to DMARDs (outlined below), also consider oral NSAIDs when control of pain or stiffness is inadequate

Step up treatment if treatment target has not been achieved despite dose escalation.

Step 1

Conventional DMARD monotherapy with oral methotrexate / leflunomide / sulfasalazine

• To be started ASAP and ideally within 3 months of symptom onset
• Consider hydroxychloroquine in mild RA or palindromic rheumatism

Consider short-term bridging steroid therapy (route as determined for flares in above section) when starting a new DMARD.

Step 2

Add a conventional DMARD to the existing monotherapy, any of the following:

• Methotrexate
• Leflunomide
• Sulfasalazine
• Hydroxychloroquine

Step 3

If no adequate response to 2 conventional DMARDs used in combination → offer methotrexate + biological DMARD

Choice of biological DMARD:

• 1st line: TNF inhibitors (adalimumab, etanercept, infliximab)
• 2nd line:
  • JAK inhibitors (filgotinib, tofacitinib, baricitinib, upadacitinib)
  • T cell inhibitor (abatacept)

• If severe RA (DAS28 >5.1) inadequately responded to at least 1 TNF inhibitor → rituximab (+ methotrexate)

Monitoring Treatment

Measure / assess the following to monitor treatment:

• CRP
• DAS28
• Health Assessment Questionnaire (HAQ) to measure functional ability

References

Original Guideline