Chronic autoimmune symmetrical polyarthritis with synovitis; high risk of joint damage and CVD.
History taking
- • Symmetrical small-joint pain + stiffness >1 h morning
- • Fatigue, weight loss
- • Family history autoimmune
Examination
- • MCP/PIP/wrist synovitis
- • Boutonnière, swan-neck, ulnar deviation late
- • Rheumatoid nodules
Red flags
- • Atlanto-axial subluxation
- • Vasculitis, scleritis, ILD
Differential diagnosis
- • See differentials section per chief complaint
Recommended investigations
- • RF, anti-CCP
- • ESR, CRP
- • X-ray hands/feet (erosions)
- • CBC, LFT, RFT pre-DMARDs
Diagnosis
- • ACR/EULAR 2010 score ≥6
Initial treatment / management
- • Early DMARD (treat to target)
- • Bridge with NSAID/steroid
Drug therapy
- • Methotrexate 7.5–25 mg PO weekly + folic acid 5 mg weekly (different day)
- • Hydroxychloroquine 200 mg BD adjunct
- • Sulfasalazine 1 g BD
- • Biologic (TNFi) if inadequate response
Follow-up advice
- • DAS28 monthly until remission
- • Monitor LFT, CBC on MTX 4–12 weekly
Patient counselling
- • Smoking cessation (reduces severity, improves drug response)
- • Vaccination before biologics
Referral criteria
- • Rheumatology within 6 weeks of suspected RA
Clinical pearls
- • Window of opportunity: DMARD within 3 months changes prognosis
References
- • Harrison's Principles of Internal Medicine, 21e
- • NICE / WHO guidelines (current edition)
Educational outpatient guide — verify against local guidelines before clinical use.
