- Early Morning stiffness (> 30 minutes)
- 3 or more swollen joints
- Metatarsal phalangeal joints (MTP) and or Metacarpophalangeal (MCP) joint involvement
- Positive Rheumatoid factor (> 18 IU/ml) provided other features present
- Characteristic distribution for inflammatory arthritis (not base of thumb or DIP joint)
- First degree relative with inflammatory arthritis
- Erosions on hand or feet Xray
- Benefit from NSAID or corticosteroids
There is a likely ‘window of opportunity’ in the first 2 years of disease onset with increased chances of inducing remission.
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Therapies used in early rheumatoid arthritis: Â
Depot Kennalog 80 mg IM (or oral/pulse steroids)
Useful as a ‘bridge’ for rapid symptom relief whilst awaiting investigations and or DMARDs to become effective
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Combination therapy:
Methotrexate 7.5 mg per week rapidly increasing every 2-3 weeks to 15-20 mg per week (with folic acid 5 mg weekly) plus
Sulphasalazine EN 500mg per day rapidly increased to 2 gm per day plus
Hydroxychloroquine 400mg per day reduced to 200mg per day after 2 months. Subcut MTX is being used more frequently and may produce less nausea and be more effective.ÂLeflunomide may also be used and the biologic therapies where indicated.
Single agents may be used rarely in selected patients.
Notes
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Rheumatoid Factor:
Not always positive early in disease
Levels only minimally raised are often not significant and positive levels do not always mean a diagnosis of RA
Anti-CCP antibodies maybe more sensitive and are more specific than RF in early RA
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Blood Tests:
ESR and CRP not always raised early in disease
Screen for Lupus:
Do an ANA especially in young and middle aged women
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Examination:
Synovitis
Joint Swelling and warmth with inactivity stiffness
Characteristic joints in early RA:
Wrists, MCP and PIP joints
MTP in feet
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Pre-menopausal women don’t get gout (almost never!). Young men do. It’s the patients responding to NSAIDs that we want to see.