Rheumatoid Arthritis: Management

Key points

• NICE NG100: offer conventional DMARD MONOTHERAPY (oral methotrexate, leflunomide or sulfasalazine) as first-line, ideally within 3 months of persistent symptom onset, with a short course of bridging glucocorticoid · hydroxychloroquine may be considered for mild or palindromic disease.
• TREAT TO TARGET: aim for remission or low disease activity · measure CRP and disease activity (DAS28) monthly in active disease and escalate treatment until the target is reached.
• Step up to additional conventional DMARDs in combination if the target is not met · methotrexate needs FBC and LFT monitoring (myelosuppression, hepatotoxicity) and carries a pneumonitis risk · it is teratogenic and contraindicated in pregnancy.
• Biologic therapy (TNF inhibitors: etanercept, infliximab, adalimumab; or alternatives such as rituximab, tocilizumab, abatacept, or JAK inhibitors) when there has been an inadequate response to at least two conventional DMARDs including methotrexate, and disease activity remains high (DAS28 > 5.1).
• Screen for latent tuberculosis and hepatitis B before starting a TNF inhibitor · etanercept is a decoy TNF receptor given subcutaneously, with demyelination risk; infliximab is a monoclonal anti-TNF-α antibody.
• MHRA (April 2023) JAK inhibitor safety: use a JAK inhibitor only if there is no suitable alternative in people aged 65 or over, current or past long-term smokers, or those with other risk factors for cardiovascular disease or malignancy · use with caution if there are other VTE risk factors · carry out periodic skin examinations.
• Adjuncts: analgesia, NSAIDs with gastroprotection, physiotherapy and occupational therapy, and surgery · assess and manage cardiovascular risk, which is raised in rheumatoid arthritis.

Decision points in this pathway

• Target not reached on the first DMARD?
• Inadequate response to at least TWO conventional DMARDs including methotrexate, with DAS28 above 5.1?

The full step-by-step algorithm, including what to do at each branch, opens in the app for approved members.