How to Treat Arthritis Rheumatoid?

Things to note:
  • Manage by co-ordinated multidisciplinary care.
  • The primary objective is to improve and maintain functional status.
  • Early use of non-drug measures, especially nursing, physiotherapy and occupational therapy, is essential.
  • Acute flare-ups: rest affected joints and consider the use of day and/or night splints.

Medical Treatment:
All patients with suspected RA should be seen at an early stage by a specialist. Evaluate all patients with suspected RA for disease-modifying anti-rheumatic drug (DMARD):
  • Methotrexate, (preferred initial therapy)
  • Chloroquine sulphate
  • Sulfasalazine
Use DMARDs only with regular monitoring for toxicity, particularly retinal toxicity caused by chloroquine and adverse effects of methotrexate i.e. bone marrow, liver toxicity, etc.
Assess response by monitoring the number of swollen and tender joints, restricted to 28 joints (shoulders, elbows, wrists, 5 metacarpophalangeal joints, 5 proximal interphalangeal joints and knees bilaterally) together with ESR or CRP. Titrate the dose of sulfasalazine and methotrexate gradually to maintenance dose.
* Methotrexate, oral, 7.5mg once per week. Specialist consultation.
  • Increase dose gradually to a maximum of 25 mg per week.
  • Monitor: Liver function and FBC before and 12 weekly during treatment.
* Folic acid, oral, 5 mg per week with methotrexate at least 24 hours after the methotrexate dose.
* Chloroquine sulphate, oral, 150mg (as base) daily for 5 days of each week for 2-3 months.
  • Then reduce dose if possible and administer 5 days a week with an annual drug holiday for 1 month.
  • Do ophthalmic examination annually to monitor for ocular damage.
* Sulfasalazine, oral, 500 mg 12 hourly.
  • Gradually increase over one month from 500 mg to 1 g 12 hourly.
  • Liver function and FBCs monthly for first 3 months then every 3-6 months.

Oral corticosteroids
  • As bridging therapy while waiting for DMARDs to take effect.
  • The elderly if threatened by functional dependence and intolerant to NSAIDs.
  • Extra-articular manifestations, e.g. pleural effusion, scleritis.
Acute flare
* Prednisone, oral, 40 mg daily for 2 weeks.
  • Thereafter gradually reduce the dose to equal to greater than 7.5 mg daily.
  • The continued need for systemic steroids should always prompt review of treatment.
Patients requiring corticosteroids for longer than 3 months should be educated to take in enough calcium in their diet.
For pain:
* Paracetamol, oral, 1g 4-6 hourly when required to a maximum of 4 doses per 24 hours.

When to refer:
  • For joint replacement.

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