How should I approach the management of a patient diagnosed with rheumatoid arthritis in primary care?

Initial management in primary care: Refer any adult with a confirmed diagnosis of rheumatoid arthritis (RA) to a specialist rheumatology service promptly, especially if persistent synovitis affects multiple small joints or if symptoms have lasted 3 months or more. Do not delay referral for investigations such as rheumatoid factor, anti-CCP antibodies, or X-rays of hands and feet, but these can be performed if it does not delay referral.

Investigations: Offer blood tests for rheumatoid factor and anti-CCP antibodies if not already done, and X-ray the hands and feet to assess for erosions. Measure functional ability using tools like the Health Assessment Questionnaire (HAQ) to establish a baseline.

Treat-to-target approach: Aim for remission or low disease activity using disease-modifying anti-rheumatic drugs (DMARDs) as per specialist advice. Use oral NSAIDs only at the lowest effective dose for the shortest time, with a proton pump inhibitor to reduce gastrointestinal risk, and review adverse event risk factors regularly.

Multidisciplinary care: Ensure the patient has access to a multidisciplinary team including specialist nurses, physiotherapists, occupational therapists, and podiatrists for ongoing assessment and support. Provide access to psychological interventions to help with adjustment to living with RA.

Monitoring and follow-up: Facilitate rapid access to specialist care for flares and ensure ongoing drug monitoring. Arrange review appointments 6 months after achieving treatment targets and annual reviews to assess disease activity, comorbidities, complications, and functional status. Consider cautious step-down of therapy after sustained remission.

Non-pharmacological management: Encourage specialist physiotherapy and occupational therapy to improve fitness, joint flexibility, and function. Consider tailored hand exercise programs and podiatry assessment for foot problems. Advise on diet and complementary therapies, emphasizing that conventional treatment should not be replaced.