Arthritis, rheumatoid

M06.90-99

DESCRIPTION

A chronic inflammatory systemic condition. May affect many organs, but the musculoskeletal system is predominantly affected with several joints becoming painful and swollen. There is usually symmetrical involvement of small joints from early on. The small joints of the fingers and hands with the exception of the distal interphalangeal joints, are usually involved, although any joint can be involved.

  • Four ‘S factors’ are useful to screen for early joint disease:
    • Stiffness: Early morning stiffness lasting > 30 minutes.
    • Swelling: Persistent swelling of 1 or more joints, particularly hand joints.
    • Squeeze test hands: Tenderness on squeezing across all 4 metarcarpo-phalangeal joints.
    • Squeeze test feet: Tenderness on squeezing across all 4 metartarso-phalangeal joints.

Late disease may have destruction and deformity of affected joints especially of the fingers e.g. ulnar deviation, buttonhole and swan neck deformities.

LoEIII [1]

GENERAL MEASURES

  • Advise patient to:
    • reduce weight
    • stop smoking
  • Manage co-morbidities.
  • Educate on joint-care (refer for occupational therapy, if available).

MEDICINE TREATMENT

All newly diagnosed patients must be referred for specialist management with Disease Modifying Anti-rheumatic Drugs (DMARDs).

For control of acute symptoms whilst awaiting referral (Doctor initiated):

  • NSAIDs, e.g.:
  • Ibuprofen, oral, 400 mg 8 hourly with or after a meal for 2 weeks .
    • Continue for no longer than 3–6 months.

For control of acute symptoms during disease flares and in severe extra-articular manifestations e.g. scleritis (Doctor prescribed):

  • NSAIDs, e.g.:
  • Ibuprofen, oral, 400 mg 8 hourly with or after a meal for 2 weeks.

LoEIII [2]

NSAIDs are used for symptomatic relief in patients with active inflammation and pain. They have no long-term disease modifying effects. NSAIDs are relatively contra-indicated in patients with significantly impaired renal function, i.e. eGFR < 60 mL/minute.

CAUTION: NSAIDS
Concomitant use of more than one oral NSAID has no additional clinical benefit and only increases toxicity.

Chronic use of all NSAIDsis associated with increased risks of gastrointestinal bleeding, renal failure, and cardiovascular events (stroke and myocardial infarction).

NSAIDs should be used judiciously at the lowest effective dose for the shortest duration. Explore and manage exacerbating factors for pain. See: Pain.
Do not use NSAID in pregnancy and breastfeeding.


If NSAIDS are contraindicated for acute flares e.g. warfarin therapy, renal dysfunction (Doctor prescribed):

LoEIII [3]

  • Corticosteroids (intermediate-acting) e.g.:
  • Prednisone, oral, 7.5 mg daily for a maximum of 2 weeks.

LoEII [4]

In high-risk patients: > 65 years of age; history of peptic ulcer disease; on concomitant warfarin, aspirin, or corticosteroids:

LoEII [5]

ADD

  • Proton pump inhibitor, e.g.
  • Lansoprazole, oral, 30 mg daily whilst on an NSAID.

For confirmed rheumatoid arthritis, NSAIDs and corticosteroids will be continued by a specialist as bridging therapy until DMARDs have taken effect.

REFERRAL

Urgent (to a specialist)

Severe extra-articular articular manifestations.

Non-urgent

  • Refer all patients early for confirmation of diagnosis and management.
  • Known rheumatoid arthritis patients with acute disease flares.