IA Injection Isolated Synovitis — SCE Rheumatology MCQ

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EasyRheumatoid ArthritisIA Injection Isolated SynovitisSCE Rheumatology

A 55-year-old woman with rheumatoid arthritis has persistent painful synovitis of her right knee despite otherwise well-controlled disease on stable DMARD therapy. Her DAS28-CRP is 2.3, and no other joints are tender or swollen. Synovial fluid culture is negative and no crystals are identified. What is the most appropriate next treatment?

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Correct answer: E — Intra-articular glucocorticoid injection

The correct answer is **A: intra-articular glucocorticoid injection**. She has an isolated monoarticular RA flare while overall disease activity is controlled, and infection and crystal arthritis have been excluded. EULAR advises that local glucocorticoid treatment may be sufficient for a monoarticular or oligoarticular flare; systemic DMARD reassessment is more appropriate for persistent polyarticular activity. Increasing oral prednisolone exposes the whole patient to glucocorticoid toxicity when treatment can be localised. Switching biologic or escalating conventional DMARD therapy would be disproportionate to a single-joint flare. Surgical synovectomy is considered only when persistent localised synovitis has failed optimal non-surgical management. Injection dose and the need for image guidance should be individualised rather than specified as universal rules.

Reference: NICE NG100. Rheumatoid arthritis in adults: management — Glucocorticoids and flare management; referral for surgery. 2018, updated 2020/2024. https://www.nice.org.uk/guidance/ng100/resources/rheumatoid-arthritis-in-adults-management-pdf-66141531233989