Rheumatoid Arthritis

Diagnosis

1. The diagnosis is essentially a clinical one, relying particularly in the early stages on the history and examination of the patient, with blood and imaging sometimes helping to confirm.
2. By convention symptoms need to have persisted for more than 6 weeks to ensure that patients with self limiting forms of arthritis are not misdiagnosed as RA
3. The American College of Rheumatology and European Alliance of Associations for Rheumtaology 2010 criteria can be applied to patients with definite synovitis in at least one joint
4. Such patients can be classified with RA if they score 6 or more points

ARA Criteria for Identifying Early RA

Note: Patients receive the highest point level they fulfil within each domain. For example, a patient with five small joints involved and four large joints involved scores 3 points.
¹defined as more than the upper limit of normal but not higher than three times the upper limit of normal
²defined as more than three times the upper limit of normal

Identifying Active Synovitis

1. RA is a deforming symmetrical polyarthritis affecting small joints of hands, feet and wrists
2. An active synovitis identifies patients with an inflammatory arthritis who will benefit from Methotrexate.
3. Inflammation manifests as pain, swelling, heat, stiffness and loss of function
4. Occasionally joint will be red in RA but this should always raise suspicion of infection.
5. Widespread synovitis may also cause systemic upset with malaise, fatigue, fever, sweats and weight loss

Investigations

1. Xray hands and feet early in course of disease if persistent synovitis in these joints
2. Check RF in suspected RA if found to have active synovitis
3. Consider anti-CCP antibodies in suspected RA if RF negative

Management of Early RA

1. Relief of symptoms
2. Disease modification
3. Refer all active synovitis to Rheumatology MDT asap
4. Ensure patient has access to named member of Rheumatology MDT

Relief of Symptoms

1. Commonly use paracetamol +/- NSAID
2. Rx Paracetamol 1G qds to max of 4G in 24 hours but consider dose reduction if <50kg, chronically malnourished or alcoholic
3. Rx ibuprofen 400-600mg tds after food, with PPI in those at high risk of GI adverse effects

Patients at Risk of Serious NSAID GI Effects

1. Age ≥65 years
2. History of peptic ulcer, perforation or GI bleeding
3. Coprescription of drugs that increase risk of Gi adverse effects eg aspirin, warfarin, steroids, SSRIs
4. Significant comorbidity eg cardiac, renal or liver failure, diabetes
5. Need for prolonged NSAID use
6. High dose NSAID eg Ibuprofen 2400mg/day

Disease Modification

1. The earlier DMARDs are started the less long term joint destruction will occur
2. Use Methotrexate as anchor drug.  Other conventional DAMRDs which can be used are Hydroxychoroquine, Sulfasalazine and Leflunomide.  A gradually tapered course of steroid may be given as bridge therapy while waiting for the DMARD action to kick in.
3. Rx a combination of MTX with at least one other DMARD plus short term steroid – Prednisolone 7.5-10mg od for up to 3/12 – as first line therapy as soon as possible and ideally within 3/12 of onset of persistent symptoms
4. If sustained and satisfactory disease control achieved then try cautious reduction in drug doses to levels which still maintain disease control.
5. If combination therapy not appropriate or poorly tolerated and DMARD monotherapy started then place greater emphasis on fast escalation to clinically effective dose than on the choice of DMARD

Sulphasalazine

1. Used for RA and peripheral arthritis in spondoarthropathy
2. Initially 500mg od, increasing by 500mg at intervals of 1 week to a maximum of 40mg/kg daily in divided doses
3. Side effects – nausea, myelosuppression, transaminitis, rash, diarrhoea, reversible male subfertility

Leflunomide

1. Used for RA,
2. 20mg od
3. Side effects – diarrhoea, hypertension, myelosuppression, rash. Leflunomide has an entero-hepatic circulation and a very long half life. Use of Cholestyramine (see BNF) to eliminate the drug if withdrawn because of side effects

Hydroxychloroquine

1. Used for RA, SLE
2. Initially 400mg od, maintenance 200-400mg od
3. Side effects – retinal toxicity, especially maculopathy. All require eye screening.

Cytokine Modulators (The Biologic and the Targeted Synthetic DMARDs)

1. Highly effective but also highly expensive drugs that tend to be used after at least two conventional DMARDS have failed
2. TNF alpha blockers – Etanercept, Infliximab, Adaluminab – are usually given in combination with Methotrexate
3. Monoclonal antibodies – Rituximab (antiCD20 positive B cells) and Tociluzimab (anti IL-6) – are reserved for use if TNF alpha blockers fail. Both are usually given with Methotrexate.
4. The JAK inhibitors – Tofacitinib, Baricitinib, Upadacitinib and Fligotinib
5. Side effects of all these drugs include severe infections including reactivation of TB – important to alert Rheumatology team and stop at least temporarily if patient admitted with significant infection

Obsolete DMARDS: Only used where others fail

1. Gold
2. Penicillamine
3. Azathioprine
4. Cyclophosphamide
5. Cyclosporin

Links

• NICE CG79 Rheumatoid Arthritis, 2009
• SIGN 123 management of early Rheumatoid Arthritis, 2011

Content updated by Dr Richard Akintayo