How should I initiate treatment for a newly diagnosed patient with rheumatoid arthritis, and what monitoring is required?

Initiation of treatment for newly diagnosed rheumatoid arthritis (RA):

• Offer first-line treatment with conventional disease-modifying anti-rheumatic drug (cDMARD) monotherapy as soon as possible and ideally within 3 months of symptom onset. Preferred options include oral methotrexate, leflunomide, or sulfasalazine. Hydroxychloroquine may be considered for mild or palindromic disease as an alternative.
• Escalate the dose of the chosen cDMARD as tolerated until the treatment target of remission or low disease activity is achieved.
• Consider short-term bridging treatment with glucocorticoids (oral, intramuscular, or intra-articular) when starting a new cDMARD to control symptoms while waiting for the DMARD to take effect (usually 2–3 months).
• If the treatment target is not achieved despite dose escalation, offer additional cDMARDs in combination using a step-up strategy.
• Once remission or low disease activity is maintained for at least 1 year without glucocorticoids, consider cautiously reducing or stopping drug doses in a step-down approach, with prompt return to previous regimen if disease worsens.

Monitoring requirements:

• Initial DMARD initiation and monitoring should be done by a specialist in secondary care.
• Once stable, ongoing prescribing and monitoring of conventional DMARDs may be undertaken in primary care under a shared care agreement, following local protocols.
• Regular blood tests are required to monitor for adverse effects and toxicity; trends in parameters (e.g., blood counts, liver enzymes) are important.
• People on DMARDs are more prone to infections, especially in the first 6 months; advise avoidance of contact with chickenpox or shingles and offer pneumococcal and annual influenza vaccinations.
• Adults with RA should have rapid access to specialist care for flares and an annual review to assess disease activity, functional ability (e.g., Health Assessment Questionnaire), comorbidities, complications, and the impact of disease on life.
• For those on biological or targeted synthetic DMARDs, clinical review in secondary care at least every 6 months is required, with monitoring blood tests usually done at these appointments.