How to treat and manage rheumatoid arthritis?

Treatment and management strategies for rheumatoid arthritis (RA) include:

• Pharmacological treatment: Initiate conventional disease-modifying anti-rheumatic drugs (cDMARDs) as first-line therapy ideally within 3 months of symptom onset, with methotrexate preferred, or alternatives such as leflunomide, sulfasalazine, or hydroxychloroquine for mild disease. Dose escalation is based on tolerance and response to achieve remission or low disease activity (treat-to-target strategy) ²,¹.
• Bridging therapy: Use short-term glucocorticoids (oral, intramuscular, or intra-articular) when starting a new cDMARD to control symptoms while waiting for DMARD efficacy (2–3 months). Long-term glucocorticoids are only considered after specialist advice and when other options have been exhausted ¹,².
• Step-up therapy: Add additional cDMARDs in combination if treatment targets are not met with monotherapy. If disease remains severe or refractory, biological DMARDs (e.g., adalimumab, etanercept, infliximab, abatacept) or targeted synthetic DMARDs (e.g., JAK inhibitors) may be offered, often in combination with methotrexate ¹,²,⁷,¹⁰.
• Symptom control: Use nonsteroidal anti-inflammatory drugs (NSAIDs) at the lowest effective dose for the shortest duration, with proton pump inhibitors to reduce gastrointestinal risk. NSAIDs should be used cautiously, especially if the patient is on low-dose aspirin ¹,².
• Non-pharmacological management: Access to multidisciplinary care including specialist physiotherapy, occupational therapy, podiatry, and psychological interventions to improve function, manage pain, and support coping strategies ².
• Monitoring and review: Regular assessment of disease activity (e.g., DAS28, CRP), functional ability (e.g., HAQ), and comorbidities annually. Drug monitoring for DMARDs is essential and can be shared between primary and secondary care ¹,².
• Vaccinations: Offer pneumococcal and annual influenza vaccinations as appropriate ¹.
• Surgical referral: Refer early for specialist surgical opinion if there is persistent pain, worsening function, deformity, tendon rupture, nerve compression, or other complications not responding to medical management ¹,².
• Lifestyle advice: Encourage smoking cessation, sensible alcohol intake, and a Mediterranean diet to reduce cardiovascular risk ¹.
• Patient education: Provide verbal and written information to improve understanding and support self-management, including access to specialist nurses and educational programmes ¹,².