Rheumatoid arthritis and DMARs
Questionnaire/history:
Stiffness in the morning and after inactivity that usually lasts more than 30 minutes?
Synovitis?
- Pain?
--- Pain usually worse at rest or during periods of inactivity?
- Swelling?
- Heat in affected joints?
Past medical history?
Current medication?
Known drug allergies?
Examination:
Swelling?
- Around the joint (not bone swelling) giving a ‘boggy’ feel on palpation?
Heat in affected joints?
Symmetrical synovitis of small joints (usual)?
- Hands?
- Feet?
- Other joints?
Positive metacarpophalangeal squeeze test?
Investigations:
ESR/CRP?
Rheumatoid factor?
Anti-CCP antibodies?
X-rays of hands and feet?
Management:
Urgent referral (even if ESR/CRP, rheumatoid factor and anti-CCP antibodies are normal) if
- Small joints of hands or feet affected
- More than one joint is affected
- Delay of ≥ 3 months between symptom onset and seeking medical advice
Advised:
NSAIDs with PPI cover but use at the lowest effective dose for the shortest possible time (try to avoid if patients need low dose aspirin for CVD)
Not to start steroids while awaiting referral as decisions on oral steroids should be made by secondary care
DMARDs/biologics and acute infections:
Conventional DMARDs:
During serious infection methotrexate, leflunomide, sulfasalazine, azathioprine, mycophenolate, ciclosporin and tacrolimus should be temporarily discontinued and specialist advice should be sought, especially if there is impaired renal function or sepsis
Biologics:
If a patient has evidence of active infection requiring antibiotic or antifungal therapy (regardless of severity), the biological agent should be withhold and the infection treated urgently; restart of the biolocial agent on advice from the specialist rheumatology team
Patients on biologic agents may not respond to the standard short course of antibiotics and may need longer courses (refer to local antibiotic guidelines for antibiotic choice and duration)
If there are symptoms of viral illnesses, consider holding the biologic agent, if a dose is due imminently and seek advice from the rheumatology specialist team
Resource(s):
Information for patient/carer(s):