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
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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
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