Rheumatoid arthritis is chronic inflammation of more than one joint causing pain and stiffness. Please refer to the diagnosis and classification criteria as mentioned at the bottom. Treatment options are based on individual patient selection for any of the treatment options given below or a combination of all three options.
Medications:
Week 1 – Tab. Saaz DR (Sulfasalazine 500 mg) 1 tablet once a day with meals.
Week 2 – Tab. Saaz DR (Sulfasalazine 500 mg) 1 tablet twice a day with meals.
If optimum results are not achieved
Week 3 – Tab. HCQS 200 (Hydroxychloroquine 200 mg) – 1 tablet once a day.
Week 4 – Tab. HCQS 200 (Hydroxychloroquine 200 mg) – 1 tablet twice a day.
If optimum results are not achieved
Week 5 – Tab. Oncotrex 2.5 mg (Methotrexate 2.5 mg) – one tablet once a week after breakfast. Increase the dose by 2.5 mg every week to maximum of 7.5 mg per week (given over 2 consecutive days).
General advice:
- Alternate local cold and heat therapy depending on patient tolerance.
- Rest the local area during flare up.
- Passive and active mobility exercises once flare up subsides.
- Consider patient for ultrasound therapy to improve physical rehabilitation.
- Suggest use of kinesiology tape (FX tape) to reduce strain on the affected joint.
Investigation:
- Rheumatoid factor (RF) – for diagnosis of rheumatoid arthritis
- Anticyclic Citrullinated Peptide Antibody (ACPA) – for diagnosis of rheumatoid arthritis
- X ray Wrist and ankle (PA and Lateral views) – to identify arthritic changes due to rheumatoid arthritis
- CRP – to monitor disease progression
- Complete blood count – to correct anemia and monitor for pancytopenia
- Liver function test, Renal function test – to identify need to adjust dosage of medications
- HBsAg and Hepatitis C antibody – to rule out hepatitis
- X ray Chest PA and Lateral view – to rule out tuberculosis
- Mantoux test – to rule out tuberculosis
Referral:
Consider referral to rheumatologist if patient fails to respond to these treatments or presents with additional complications. Referral to orthopaedics may be needed especially if patient has bony deformity affecting quality of life.
ACR / EULAR Rheumatoid Arthritis Classification Criteria:
Joint involvement – small joints (wrists, hands, and feet); large joints (shoulders, elbows, hip joints, knees, and ankles)
- 0 point – Involvement of 1 large joint
- 1 point – Involvement of 2 – 10 large joints
- 2 points – Involvement of 1 – 3 small joints (with or without involvement of large joints)
- 3 points – Involvement of 4 –10 small joints (with or without involvement of large joints)
- 5 points – Involvement of more than 10 joints (with involvement of at least 1 small joint)
Serological parameters – rheumatoid factor and ACPA
- 0 point – Negative RF and negative ACPA
- 2 points – Low-positive RF or low-positive ACPA
- 3 points – High-positive RF or high-positive ACPA
Additional factors
- 1 point – for elevated erythrocyte sedimentation rate, ESR, or elevated CRP value (c-reactive protein)
- 1 point – for symptoms lasting six weeks or longer
Total score of 6 or more is required for diagnosis of Rheumatoid arthritis.