This algorithm applies to men and women aged more than 16 years presenting withjoint pain and swelling. Refer to RACGP Clinical guidelines for musculoskeletal diseases

for more information on recommendations and grading of evidence www.racgp.org.au/guidelines/musculoskeletaldiseases

Early diagnosis and management of rheumatoid arthritis

SuSpected RAConsider any of the following:History (B)• Jointpainandswellingand/orfever• Morningstiffness>30minutes• Previousepisodes• FamilyhistoryofRA• Systemicflu-likefeaturesandfatigue

INItIAL tHeRApYPharmacological interventions• Simpleanalgesics(eg.paracetamol)(B)• Fattyacids:omega-3supplements(A),higherdosesofomega-3

arelikelytobeofgreatestbenefit(upto12g/day),gammalinoleicacidsupplements(C)

• NSAIDs/COX-2inhibitors(A)• DMARDs(A)• Corticosteroids(oral: A, intra-articular: B)

Nonpharmacological interventions• Weightcontrol(B)• Patienteducationandselfmanagementprograms(B)• Occupationaltherapy(B)• Exercise(eg.dynamic,aerobic,taichi)(C)• Psychosocialsupport(C)• Sleeppromotion(B)• Appropriatefootcare(C)• Thermotherapy(eg.heatand/oricepacks)(D)

Refer to rheumatologist or specialist (A)• Immediatelywhenmultipleswollenjoints,particularlyifRhFand/or

anti-CCPantibodyarepositive• IfstillrequiringNSAIDsbeyond6weeksafterinitialtreatment

ONGOING MONItORING(shared care between patient, GP and rheumatologist)• Jointeffects:number,tendernessandswelling• Extra-articular(eg.nodules,rash)• CVD:BPandotherriskfactors,andrenalfunction• Riskofinfection(immunomodulators)• Toxicity:monitorforpotentialtoxicity(eg.skin,lungs,GIT,heart,

bloodand/orurinetests)• Lifestyle(eg.smoking,weight,BMI)• Activitiesofdailyliving(eg.function,sleep,mood,fatigue)• Annualfootreview• Medicationadherence• Iflongtermcorticosteroids,reviewosteoporosisrisk,BP,lipids,

cataracts

cLINIcAL exAMINAtION (B)• Threeormoretender

and swollen joint areas• Symmetricaljointinvolvement

inhandsand/orfeet• PositivesqueezeatMCP

or MTPjoints

OR in consultation with rheumatologist or specialist (ifimmediateaccessisnotavailable)• DMARDs(eg.methotrexateonceweekly)(A)• Shorttermlowdoseoralcorticosteroids (7.5mg/day)(A)

If persistent swelling beyond 6 weeks (even if RhF and/or anti-CCP negative) and/or inadequate pain relief consider referral

AdvANced tHeRApY(prescribed by a rheumatologist) Forexample:eflunomide,cyclosporin,biologicalagents,etanercept,adalimumab,infliximab,anakinra,rituximab

ConsiderDMARDswhenthereareseveralswollenjoints,especiallyiftestsforRhFand/oranti-CCParepositive(inconjunctionwithreferraltoarheumatologist)

RA may present in other ways. Investigations to consider based on clinical judgment• Clinicalhistoryandexaminationtorule

outothercauses• Considerarangeofinfections(eg.

hepatitisBandC,rubella,parvovirus,entericinfectionsorfibromyalgia)thatmaycausepolyarthritis

Diagnostic investigations (A)• RaisedESRand/orCRP• Positiverheumatoidfactor(RhF) and/oranti-cycliccitrullinatedpeptide

antibodies (anti-CCP)

Absence of any of these key symptoms, signs or test results does not necessarily rule out RA

RA algorithm_260x200.indd 1 8/06/10 11:35 AM

Early diagnosis and management of rheumatoid arthritis

SeLected pRActIce tIpS (See tHe FuLL GuIdeLINe FOR MORe tIpS ANd FuRtHeR detAILS)www.racgp.org.au/guidelines/rheumatoidarthritis

Intervention Recommendation

Pharmacological management

Simpleanalgesics • Prescribeparacetamolinregulardivideddosestoamaximumof4g/dayfortreatingpersistentpain

Fattyacidsupplements(omega-3andgamma-linolenicacid)

• Omega-3supplementationasanadjunctformanagementofpainandstiffnessinpatientswithRA(Recommendation 13 A)

• Higherdosesofomega-3arelikelytobeofgreatestbenefit(upto12g/day)• FattyacidinterventionmayprovidesupplementaryoralternativetreatmenttoNSAIDsinsomepatients.TheycanalsoenableareductionofNSAIDs

• Therecommendeddoseforgamma-linolenicacid(GLA)is1400mg/dayofGLAor3000mgofeveningprimroseoil

TraditionalNSAIDsandCOX-2inhibitors

• ConsiderusingconventionalNSAIDsorCOX-2inhibitorsforreducingpainandstiffnessintheshorttermtreatmentof RAwheresimpleanalgesiaandomega-3fattyacidsareineffective(Recommendation 15 A)

•OnlyoneNSAIDorCOX-2inhibitorshouldbeprescribedatanyonetime

DMARDs • InvestigationsbeforeDMARDtherapy:chestX-ray,FBC,ESR,CRP,hepatitisBandC,renalandliverfunctiontests• CommenceDMARDswithin12weeksofonsetinconsultationwitharheumatologist• Onceweeklymethotrexateisfirstchoiceasasingleorcombinationtherapyunlesscontraindicated• DMARDsrequireatleast2–3monthstotakeeffect• Ceasesmokingandlimitalcoholifonmethotrexateorleflunomide(Recommendation 17 and 18 A)

Corticosteroids • Intra-articularforindividualjointstosuppresssynovitis• Oral,IMorIVforgeneralflarewhilewaitingforDMARDaction• Lowdoseoralcorticosteroids(7.5mg/day)mayhaveDMARDactionbutlongtermuseisnotrecommended• OngoingmonitoringformedicationsafetyandcomorbiditiesisanimportantsharedGProle• Discussmedicationinteractions(includingover-the-counterpreparationsandcomplementarymedicines)

Nonpharmacological interventions

Complementary therapies • InformpatientsaboutinsufficientvolumeofevidenceavailableontreatingRAwithcomplementarytherapies(Recommendation 21 B)

Tripterygium wilfordii WARNING: DO NOT recommend the Chinese herb Tripterygium wilfordii due to risk of serious adverse effects (Recommendation 22 B)

Exercise • Encourageregular,dynamicphysicalactivity,compatiblewiththepatient’sgeneralabilities,inordertomaintainstrengthandphysicalfunctioning(Recommendation 24 C)

Weight

Diseasemonitoringand comorbidities

• Encourageweightcontrolanddietarymodification(Recommendation 23 B)• AssessandtreatCVriskfactorssuchassmoking,obesity,physicalactivity,hypercholesterolaemia,hypertensionand diabetes

•Monitoratleast3timesperyear:CVS,GITandrenalfunction(Recommendation 16 A)

WARNING: Aggressive early treatment prevents joint damage. However, treatment may cause serious adverse effects including death. Physicians and patients must monitor for signs and symptoms of potential toxicity through regular clinical and laboratory review

FoR DetAIleD PResCRIBING INFoRmAtIoNTherapeuticGuidelineswww.tg.com.auAustralianMedicinesHandbookwww.amh.net.auNationalPrescribingServicewww.nps.org.au

PAtIeNt seRvICesArthritisAustraliawww.arthritisaustralia.com.auAustralianRheumatologyAssociationwww.rheumatology.org.au

GPsmayutiliseEPCitemstofacilitateaccesstoappropriateserviceswww.health.gov.au/epc.Eligibleservicesinclude,butarenotlimitedto,thoseprovidedbyphysiotherapists,occupationaltherapistsandexercisephysiologists;andreferforHMRwithpharmacistformedicationeducationandmanagement (Recommendation 5 B);psychologicalsupport(Recommendation 9 C);podiatristforfootcare(Recommendation 27 C)

NHmRC grades of recommendations

A Bodyofevidencecanbetrustedtoguidepractice

B Bodyofevidencecanbetrustedtoguidepracticeinmostsituations

C Bodyofevidenceprovidessomesupportforrecommendation(s)butcareshouldbe takeninitsapplication

D Bodyofevidenceisweakandrecommendationmustbeappliedwithcaution

Note:ArecommendationcannotbegradedAorBunlessthevolumeandconsistencyof evidencecomponentsarebothgradedeitherAorB

ThisprojectissupportedbytheAustralianGovernmentDepartmentofHealthandAgeingthroughtheBetterArthritisandOsteoporosisCareinitiative

Expirydateofrecommendations:August2014

Disclaimer

Theinformationsetoutisofageneralnatureonlyandmayormaynotberelevanttoparticularpatientsorcircumstances.Itisnottoberegardedasclinicaladviceand,inparticular,isnosubstituteforafullexaminationandconsiderationofmedicalhistoryinreachingadiagnosisandtreatmentbasedonacceptedclinicalpractices.AccordinglyTheRoyalAustralianCollegeofGeneralPractitionersanditsemployeesandagentsshallhavenoliability(includingwithoutlimitationliabilitybyreasonofnegligence)toanyusersoftheinformationcontainedinthispublicationforanyloss,damage,costorexpenseincurredorarisingbyreasonofanypersonusingorrelyingontheinformationcontainedandwhethercausedbyreasonofanyerror,negligentact,omissionormisrepresentationintheinformation.

©TheRoyalAustralianCollegeofGeneralPractitioners.Allrightsreserved

RA algorithm_260x200.indd 2 8/06/10 11:35 AM