Home Forums Other Specialities Sports Medicine / Physical Medicine RHEUMATOID ARTHRITIS- BACK TO BASICS.

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    Rheumatoid Arthritis: A Protocol for Early Referral and DMARD Monitoring Guidelines

    Rheumatoid arthritis (RA) continues to offer a major management challenge: patients often present with non-specific, atypical symptoms.
    The diagnosis often cannot be confirmed or refuted with diagnostic tests, hence diagnosis is difficult. Other factors that might delay diagnosis include a lack of specialist clinics and rheumatologists.

    A major step forward in the past ten years has been the realisation that early treatment with disease-modifying anti-rheumatic drugs (DMARDs) is important if the disease process is to be slowed or halted.
    The rationale behind the early initiation of disease-modifying agents in RA is based on the recognition that joint damage occurs most rapidly early in the disease.
    Early referral is essential to reduce the inflammatory course and thus reduce the potential for joint damage.
    Referral to specialist clinics also enables patients to benefit from a holistic approach to the disease facilitated by the multidisciplinary team.

    Management goals

    Relief of symptoms
    Preservation of function
    Prevention of structural damage and deformity
    Patient education
    Maintenance of patient’s normal lifestyle

    Making a diagnosis

    Complete history and clinical examination/assessment of symptoms

    Morning stiffness, fatigue
    Synovitis of three or more joint areas
    Symmetric arthritis


    The pattern of joint involvement almost always favours the MCP and PIP joints/wrists
    The swelling on palpation is characteristic. Synovial swelling is soft unlike the hard, bony swelling in diseases like OA

    Differential diagnosis

    Other inflammatory arthritis, e.g. post viral
    Non-inflammatory joint conditions
    Connective tissue diseases
    Other important diagnoses, e.g. polymyalgic rheumatica


    Full blood count
    Rheumatoid factor
    X-ray hands/feet (not necessary before referral)

    Dr G Mohan.

    If needed : Referral to Specialist-why,when and how ?
    Pharmacoligical approach?

    Can be requested from the author.

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