Educational draft · awaiting clinical reviewThe full textbook explains uncertainty but does not replace live national or local guidance, specialist advice, or current prescribing information.
Recognise rheumatoid arthritis from persistent synovitis, secure urgent specialist assessment, initiate disease-modifying treatment with safe bridging support, and adjust therapy to an agreed remission or low-activity target.
Rheumatoid arthritis is a chronic systemic inflammatory disease whose central clinical lesion is synovitis. Diagnosis is clinical and supported by distribution, duration, serology and imaging. Examine all peripheral joints, tendon sheaths, nodules and function, and ask about eye, lung, cardiac, neurological and constitutional symptoms. A classification score supports research consistency but should not replace specialist judgement in early or seronegative disease.
Early treatment changes outcome. NICE recommends specialist referral for persistent synovitis and initiation of a conventional synthetic DMARD as soon as possible after diagnosis. Methotrexate is widely used unless contraindicated; leflunomide or sulfasalazine are alternatives, with hydroxychloroquine an option in selected mild disease. Explain delayed onset, infection precautions and blood monitoring before the first dose. Methotrexate and leflunomide are incompatible with pregnancy; suspected or planned pregnancy on
Polygenic susceptibility, including HLA-related antigen presentation, interacts with environmental factors to permit loss of tolerance and persistent autoimmune synovial inflammation.
Cigarette smoking and mucosal inflammation can promote protein citrullination and autoantibody development, particularly in genetically susceptible individuals.
Rheumatoid arthritis is more common in women, while hormonal, microbial and occupational exposures modify risk without acting as a single sufficient cause.
RF, anti-citrullinated-protein immunity and activated lymphocytes amplify TNF, interleukin-6 and other cytokine networks within susceptible synovium.
Proliferative synovium invades cartilage and activates osteoclasts at the bone margin, producing erosions, joint-space loss and progressive instability.
Inflammatory mediators affect blood vessels, lung, eye, nerves and metabolism, increasing fatigue, anaemia, osteoporosis and cardiovascular risk beyond the joints.
Boggy MCP, PIP, wrist or MTP swelling with squeeze pain, prolonged stiffness and reduced grip supports active rheumatoid synovitis and early referral.
Anti-CCP positivity or baseline erosions indicate increased risk of radiographic progression and support close treat-to-target monitoring.
Breathlessness, dry cough, painful red eye, nodules, neuropathy, pleuritic pain or constitutional decline requires organ-specific assessment rather than a joint-only review.
One acutely hotter joint, bacteraemia risk or systemic illness during immunosuppression requires urgent aspiration and culture before assuming rheumatoid flare.
Pain with little synovitis may arise from deformity, osteoarthritis, tendon disease or fibromyalgia and should not trigger automatic immunosuppression escalation.
Psoriasis, nail dystrophy, DIP disease, dactylitis, enthesitis or asymmetric lower-limb arthritis suggests a spondyloarthritis rather than classic rheumatoid pattern.
Abrupt onset, exposure, rash, hepatitis, episodic attacks or synovial crystals supports infectious, post-infectious or crystal inflammation, although patterns may overlap.
Photosensitive rash, ulcers, Raynaud phenomenon, sicca, cytopenia, renal abnormality or low complement redirects assessment towards lupus or another systemic autoimmune disorder.
Bony DIP change, brief stiffness and load-related pain support osteoarthritis, while widespread tenderness without synovitis suggests a non-inflammatory pain mechanism.
Uncontrolled synovitis causes cartilage loss, marginal erosions, tendon rupture, subluxation and fixed deformity with irreversible loss of hand, foot and mobility function.
Rheumatoid nodules, interstitial lung disease, pleuritis, scleritis, neuropathy, vasculitis and cervical instability can determine morbidity independently of peripheral joint activity.
Inflammation, inactivity and corticosteroid exposure accelerate atherosclerosis, sarcopenia and osteoporosis, increasing myocardial, fracture and frailty risk.
DMARDs, glucocorticoids and comorbidity raise infection, cytopenia, hepatic and reproductive risks, requiring prevention, laboratory monitoring and rapid review of symptoms.
Normal markers, negative antibodies and normal early films must not delay specialist assessment of persistent synovitis.
Methotrexate must have one specified weekly day and separate folic-acid instructions to prevent fatal dosing confusion.
Feet, tendon disease, extra-articular inflammation, damage and pain amplification may not be represented by the score.
Escalating immunosuppression without confirming synovitis can worsen infection risk while leaving mechanical or central pain untreated.
Vaccination, smoking cessation, exercise, cardiovascular assessment and bone protection materially alter long-term rheumatoid outcomes.
Waiting for positive RF or erosions before referring persistent synovitis.
Prescribing methotrexate daily or failing to specify the weekly dose day.
Repeating glucocorticoid bridging courses without a disease-modifying escalation plan.
Calling fever or one hot joint a flare in an immunosuppressed patient without infection assessment.
Using a composite score without examining feet, tendons and extra-articular organs.
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A patient with active rheumatoid arthritis still has objective synovitis after an adequate, tolerated dose escalation of one conventional DMARD. Adherence is confirmed, infection has been excluded, and remission or low disease activity has not been achieved. What is the best next strategy?
National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.
Treat-to-target care makes reassessment explicit. Record a composite activity measure such as DAS28 where appropriate, but examine feet, tendons and extra-articular disease not captured by the score. If the target is not reached despite adherence and adequate dose, optimise or add conventional therapy and consider biologic or targeted synthetic DMARDs under NICE eligibility and specialist safety pathways. Patient preference and comorbidity shape sequencing.
Long-term care includes annual review of disease activity, function, cardiovascular risk, blood pressure, lipids, smoking, bone health, vaccination, cervical and foot problems, mood and work. Minimise cumulative glucocorticoids. Before surgery, pregnancy or serious infection, coordinate DMARD interruption or continuation with rheumatology rather than stopping all treatment without a plan.
Never prescribe or take it daily. Check risk-stratified FBC, renal function, ALT or AST and albumin; review liver, alcohol, lung, infection and interaction risks, especially trimethoprim or co-trimoxazole. Withhold during a serious infection until recovery and specialist review. For maternal exposure, low-dose methotrexate must be stopped at least 1 month before planned conception and is not compatible with pregnancy or breastmilk exposure; accidental pregnancy needs immediate cessation, folic acid 5 mg/day and specialist fetal-risk review. BSR regards paternal exposure at no more than 25 mg/week as compatible.
Monitor FBC, liver and renal function and counsel about rash, blood dyscrasia, gastrointestinal effects, sulfonamide allergy and reversible oligospermia. Use a specialist withholding and restart plan for serious infection. Sulfasalazine is compatible in pregnancy; prescribe folic acid 5 mg daily during periconception and the first trimester.
Exclude infection, assess diabetes, blood pressure, mood, eye and bone risk, protect against prolonged exposure and never stop established long-term therapy abruptly.
Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes
Check pregnancy status, blood pressure, FBC including platelets, liver tests and renal function before treatment and monitor under the BSR or specialist shared-care schedule. Avoid in pregnancy or breastfeeding, severe liver disease, serious infection or marked cytopenia. Because the active metabolite persists, planned maternal conception or serious toxicity requires specialist accelerated elimination and verification under the SmPC; do not improvise a washout.
Avoid in pre-existing maculopathy and review renal impairment, visual symptoms, hypoglycaemia, cardiac disease and QT-prolonging combinations. Arrange annual retinal monitoring after 5 years, or after 1 year when high risk: dose above 5 mg/kg actual body weight, eGFR below 60 mL/min/1.73 m², tamoxifen use or previous chloroquine. BSR considers it compatible with pregnancy, breastmilk and paternal exposure.