Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.
Rheumatoid arthritis: diagnosis and treat-to-target care
Essential points for quick revision.
2 min synopsisUK scopeSources checked 27 Aug 2026Clinical review pending
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Escalate
Escalate a single newly hot joint, sepsis, acute cervical myelopathy, scleritis, rapidly progressive neuropathy, pericarditis or severe lung disease urgently. Glucocorticoids and IL-6 blockade can blunt fever or inflammatory markers, so exclude infection before attributing deterioration to rheumatoid flare.
Synopsis
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.
Suspect rheumatoid arthritis in persistent synovitis, especially symmetrical MCP, PIP, wrist and MTP disease with prolonged morning stiffness; DIP joints are usually not the dominant site.
Refer every adult with suspected persistent synovitis of undetermined cause. Mark the referral urgent, even with normal inflammatory markers or negative serology, when small hand or foot joints are affected, more than one joint is affected, or at least three months elapsed before medical advice was sought.
RF supports but does not diagnose rheumatoid arthritis; anti-CCP is more specific and may indicate greater risk of radiographic progression.
Key red flags
Extra-articular rheumatoid disease
Breathlessness, dry cough, painful red eye, nodules, neuropathy, pleuritic pain or constitutional decline requires organ-specific assessment rather than a joint-only review.
Investigation priorities
01
Clinical joint examination and disease activity measureFirst step
Confirm synovitis, establish baseline burden and support repeated treat-to-target decisions.
Management branches
Suspected early RARefer on synovitis, not test positivity
Persistent objective peripheral-joint swelling is present without an immediate septic-joint emergency.
Document joint distribution, duration, stiffness, function and extra-articular features; offer RF and, if it is negative, consider anti-CCP. Obtain baseline bloods and radiographs in parallel without delaying referral.
Refer every suspected persistent synovitis without awaiting tests. For more than 1 joint or the small joints of the hands or feet, refer within 3 working days of primary-care presentation; also mark it urgent when symptoms began at least 3 months before medical advice was sought. Provide proportionate analgesia and avoid unreviewed prolonged glucocorticoids.
Key medicines
Methotrexate with folic acidUsually 7.5–15 mg once weekly initially, titrated by rheumatology within the product-specific maximum. Prescribe only 2.5 mg tablets, agree one fixed weekly day and co-prescribe folic acid at least 5 mg once weekly on a different day.
SulfasalazineCommonly started at 500 mg once daily and increased gradually toward 1 g twice daily according to tolerance and specialist protocol.
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.
Leflunomide UK product informationActive-RA indication, 10–20 mg once-daily maintenance dose, optional loading dose, contraindications, monitoring and accelerated-elimination procedure.
Hydroxychloroquine UK product informationAdult RA dosing, administration, macular and cardiac cautions, interactions and pregnancy/lactation information; use with the newer BSR 5 mg/kg actual-weight target.