Symmetric small-joint (MCP/PIP) pain, morning stiffness >1 h
Confirm: Anti-CCP + RF + hand X-ray
Treat: Methotrexate (anchor DMARD) + folic acid → add TNF inhibitor if inadequate; short-term steroids/NSAIDs bridge
Order set
- Anti-CCP, RF
- ESR/CRP
- Hand/foot X-rays
- FBC, LFTs, U&E (pre-DMARD)
Criteria
AdmitSeptic joint suspicion or systemic complication
DischargeDMARD started, pre-biologic screening, rheumatology follow-up
Key
- Screen TB (IGRA), hepatitis B/C, HIV before biologics. Methotrexate 7.5–25 mg weekly.
- JAK inhibitors (after MTX failure) — only after CV/malignancy/VTE risk assessment (ORAL Surveillance; EULAR 2022).
Clinical detail — differentials, red flags, pitfalls, disposition
Red flags
- Cervical spine involvement
- Vasculitis
- Rapid erosive disease
Differentials
- Psoriatic/reactive arthritis
- SLE
- Viral arthritis
- OA
Common mistakes
- Delaying DMARDs
- Skipping TB/hepatitis screen before biologics
Disposition & follow-up
Early methotrexate; rheumatology follow-up; treat-to-target.
Discharge package
MedicationsMethotrexate + folic acid ± biologic; steroid taper
Follow-upRheumatology; drug monitoring bloods
VaccinationPre-biologic screen; avoid live vaccines on immunosuppression
Warning symptomsInfection, mouth ulcers, breathlessness (MTX pneumonitis)
💊 Treatment detail — doses & preparation
MethotrexateDMARD
Dose10–15 mg PO/SC once weekly, titrate to 20–25 mg weekly + folic acid 5 mg (different day)
Preparation2.5/10 mg tablets — WEEKLY, not daily (dispensing error kills); SC pens 7.5–25 mg
MonitorFBC, LFT, creatinine q2–4 wk until stable; avoid in pregnancy/liver disease
HydroxychloroquineDMARD
Dose200–400 mg OD (≤5 mg/kg/day)
Preparation200 mg tablets
MonitorAnnual retinal screening after 5 yr; slow onset 6–12 wk
Prednisolonecorticosteroid
DoseRA flare bridge: short-term, lowest effective dose, taper ASAP (EULAR 2022) — e.g., 10–20 mg OD with rapid taper
Preparation5/25 mg tablets; gastro-resistant or plain with food
MonitorGlucose, BP, mood; bone protection if >3 mo (Ca²⁺/D ± bisphosphonate)
Folic acidvitamin
Dose5 mg OD (deficiency/methotrexate cover — give on non-MTX days)
Preparation5 mg tablets
MonitorCorrect B12 deficiency FIRST if coexisting
SulfasalazineDMARD
Dose500 mg OD, ↑weekly to 1 g BD
Preparation500 mg EC tablets with food
MonitorFBC/LFT monthly ×3 mo; orange urine, sulfa allergy
📖 ACR / EULAR RAReviewed July 2026