Arthritis, Rheumatoid (RA)

Description

General Measures

Medicine Treatment

Referral

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ICD-10 Code: M05.80-89/M05.90-99/M06.00-09/M06.80-09/M06.90-99/M08.30-39/M08.40-49/M08.80-89/M08.90-99

DESCRIPTION

A chronic, inflammatory, systemic condition with a fluctuating course. It may affect many organs, but the joints are predominantly affected. Characteristic joint manifestations are:

• Swelling or fluid, affecting at least three joint areas simultaneously.
• Pain.
• Limited movement with morning stiffness > 1 hour, which improves with activity. This helps distinguish osteoarthrosis from rheumatoid arthritis.
• Destruction and deformity of affected joints.
• The small joints of the fingers and hands, with the exception of the distal interphalangeal joints, are usually involved, although any joint can be involved.
• Arthritis is typically symmetrical.

GENERAL MEASURES

• 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.
• Obtain a baseline complete blood count, serum creatinine, alanine aminotransferase (ALT), and erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP) in all patients.
• Obtain X-rays of the hands and wrists, as well as both forefeet to include the metatarsophalangeal joints as a baseline for evaluating change in the joints during treatment.

MEDICINE 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

Monitoring response to DMARDs:

• Assess response to DMARD therapy 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.
• If there is poor response to one DMARD, after 3 months, add another DMARD. 

LoE:II¹

• Patients on DMARDs must be monitored regularly for toxicity, as outlined below:
• Methotrexate, oral, 7.5 mg once per week. Specialist consultation.
  • Increase dose gradually to a maximum of 25 mg per week.
  • Monitor: ALT and FBC before and 12 weekly during treatment.

AND

• Folic acid, oral, 5 mg per week at least 24 hours after the methotrexate dose.

LoE:II²

AND/OR

• Chloroquine sulphate, oral, 150 mg (as base) daily for 5 days of each week.
  • Do ophthalmic examination at baseline within the first year of treatment and annually thereafter, to monitor for ocular damage.

AND/OR

• Sulfasalazine, oral, 500 mg 12 hourly with meals.
  • Gradually increase over one month from 500 mg to 1 g 12 hourly.
  • FBC and ALT monthly for first 3 months then every 3–6 months. 

LoE:III³

Oral corticosteroids 

Systemic corticosteroids are effective at relieving symptoms in RA and have been shown to modify the course of the disease, but long term use is discouraged because this is associated with considerable toxicity, notably osteoporosis, which is very common in patients with RA.

Indications:

• As bridging therapy while waiting for DMARDs to take effect.
• Acute disease flares.
• Severe extra-articular manifestations, e.g. scleritis.

Corticosteroids (intermediate-acting), e.g.:

• Prednisone, oral, 40 mg daily for 2 weeks.
  • Thereafter gradually reduce the dose to  ≤ 7.5 mg daily. (Refer to Prescription Writing for an example of a dose reduction regimen).
  • Discontinue at 3–6 months.
  • If disease flares after stopping corticosteroids DMARD therapy should be optimised.

LoE:III⁴

Patients requiring corticosteroids for longer than 3 months should be educated
to take in enough calcium in their diet.

For pain:

• Paracetamol, oral, 1 g 4–6 hourly when required.
  • Maximum dose: 15 mg/kg/dose.
  • Maximum daily dose: 4 g in 24 hours.

NSAIDs

• NSAIDs are used for symptomatic relief in patients with active inflammation and pain. They have no long-term disease modifying effects.
• NSAID dose should be reduced and then stopped once the DMARDs have taken effect.
• Reduce NSAID doses in the elderly.
• NSAIDs are relatively contra-indicated in patients with significantly impaired renal function, i.e. eGFR < 60 mL/minute.

Concomitant use of more than one oral NSAID has no additional clinical benefit and only increases toxicity.
Use of all NSAIDs is associated with increased risks of gastrointestinal bleeding, renal dysfunction, and cardiovascular events (stroke and myocardial infarction).
NSAIDs should be used judiciously at the lowest effective dose for the shortest duration. Explore and manage exacerbating factors for pain. See Chronic pain.
Do not use NSAID in pregnancy or while breastfeeding.

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• NSAID, e.g.:
  • Ibuprofen, oral, 400 mg 8 hourly with meals.

LoE:I⁵

An extra night-time dose of a NSAID may be added in some patients with severe nocturnal pain/morning stiffness.

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Note
When an additional night-time dose is added to the patient’s regimen, the risk of NSAID toxicity increases. A reduction in the daytime dose of NSAIDs is recommended as the night-time dose will often exceed the recommended total daily NSAID dose.
If a reduction in daytime dose causes increased pain, then the use of the night-time dose must be for the shortest period possible.

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In high-risk patients: > 65 years of age; history of peptic ulcer disease; on concomitant warfarin, aspirin, or corticosteroids:

ADD

LoE:III⁶

• PPI, e.g.:
  • Lansoprazole, oral, 30 mg daily whilst on an NSAID.

Adjunct for pain control:

• Amitriptyline, oral, 10–25 mg at night.
  • Titrate dose according to response.
  • Initial dose in the elderly: 10 mg at night.
  • Maximum dose: 75 mg at night.
  • Use with caution in patients with angle closure glaucoma, prostatic hypertrophy and the elderly.

Intra-articular corticosteroids

Consider only in cases where a few joints are very actively inflamed.
To be prescribed by a specialist.
Not more than 2–3 injections per year per joint are recommended.

• Intra-articular corticosteroid, e.g.:
  • Methylprednisolone acetate, 20–80 mg depending on joint size. 

LoE:III⁷

REFERRAL

• At initial diagnosis.
• Disease activity cannot be controlled with the measures as mentioned.
• Compression neuropathy.
• For joint replacement.

Urgent

• Rupture of tendons.
• Scleritis.
• Unstable upper cervical spine.
• Vasculitis.
• Cricoarytenoid joint involvement with hoarseness and inspiratory stridor.

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Standard Treatment Guidelines and Essential Medicines List for South Africa, Hospital Level, Adults 2024 Edition