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.
- Obtain baseline FBC, renal and liver profile, inflammatory markers and appropriate infection, pregnancy and vaccination assessment without delaying referral.
- Start cDMARD monotherapy as soon as possible and ideally within 3 months of persistent-symptom onset: offer oral methotrexate, leflunomide or sulfasalazine, or consider hydroxychloroquine for mild or palindromic disease; escalate the selected dose as tolerated.
- Short-term glucocorticoid bridging may control inflammation while a new DMARD takes effect, but needs an explicit stop or taper plan and infection, glucose, bone and cardiovascular review.
- Measure disease activity regularly and escalate against an agreed target of remission or low activity rather than continuing an ineffective regimen by inertia.
- Separate active synovitis from fixed damage, osteoarthritis, fibromyalgia, infection and treatment toxicity before declaring DMARD failure.
Key red flags
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.
Investigation priorities
Confirm synovitis, establish baseline burden and support repeated treat-to-target decisions.
Management branches
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.
- At specialist confirmation, start cDMARD monotherapy as soon as possible and ideally within 3 months of persistent-symptom onset; QS33 measures treatment starting within 6 weeks of referral. Provide education and monitor active disease monthly until the agreed remission or low-activity target is achieved.
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.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.
SulfasalazineCommonly started at 500 mg once daily and increased gradually toward 1 g twice daily according to tolerance and specialist protocol.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.