What is the initial management of rheumatoid arthritis (RA) in the emergency department (ED)?

From the Guidelines

The initial management of rheumatoid arthritis (RA) in the emergency department should focus on pain control and reducing inflammation, with the goal of improving morbidity, mortality, and quality of life. The most recent and highest quality study, 1, recommends starting therapy with DMARDs as soon as the diagnosis of RA is made, aiming for sustained remission or low disease activity in every patient. In the ED, this can be achieved by:

• Starting with NSAIDs such as ibuprofen 400-800mg every 6-8 hours or naproxen 500mg twice daily for pain and inflammation
• Considering short-term opioids like tramadol 50-100mg every 4-6 hours for moderate to severe pain
• Using corticosteroids, such as prednisone 10-20mg daily for 5-7 days with a taper, or methylprednisolone 80-120mg IV for severe presentations, in cases of acute flares
• Performing joint aspiration to rule out septic arthritis, especially with single joint involvement, fever, or recent joint surgery
• Ordering laboratory tests, including CBC, ESR, CRP, RF, and anti-CCP antibodies, to support the diagnosis and guide treatment
• Referring patients to rheumatology for follow-up within 1-2 weeks for long-term management with DMARDs, as recommended by 1 and 1. It is essential to prioritize the patient's quality of life, morbidity, and mortality when making treatment decisions, and to consider the latest evidence-based recommendations, such as those from 1, when developing a treatment plan.

From the FDA Drug Label

Rheumatoid Arthritis including Polyarticular-Course Juvenile Rheumatoid Arthritis: Methotrexate is indicated in the management of selected adults with severe, active rheumatoid arthritis (ACR criteria), or children with active polyarticular-course juvenile rheumatoid arthritis, who have had an insufficient therapeutic response to, or are intolerant of, an adequate trial of first-line therapy including full dose non- steroidal anti-inflammatory agents (NSAIDs). Aspirin, (NSAIDs), and/or low dose steroids may be continued, although the possibility of increased toxicity with concomitant use of NSAIDs including salicylates has not been fully explored. Rheumatic Disorders As adjunctive therapy for short-term administration (to tide the patient over an acute episode or exacerbation) in: Psoriatic arthritis Rheumatoid arthritis, including juvenile rheumatoid arthritis (selected cases may require low-dose maintenance therapy) CLINICAL STUDIES General Information Naproxen has been studied in patients with rheumatoid arthritis, osteoarthritis, juvenile arthritis, ankylosing spondylitis, tendonitis and bursitis, and acutegout Improvement in patients treated for rheumatoid arthritis was demonstrated by a reduction in joint swelling, a reduction in duration of morning stiffness, a reduction in disease activity as assessed by both the investigator and patient, and by increased mobility as demonstrated by a reduction in walking time

The initial management of rheumatoid arthritis (RA) in the emergency department (ED) may involve the use of:

• NSAIDs such as naproxen to reduce joint swelling and pain
• Corticosteroids such as prednisone for short-term administration to tide the patient over an acute episode or exacerbation
• Methotrexate may be considered for selected adults with severe, active rheumatoid arthritis who have had an insufficient therapeutic response to, or are intolerant of, an adequate trial of first-line therapy including full dose non-steroidal anti-inflammatory agents (NSAIDs) 2 It is essential to note that the management of RA in the ED should be done under the guidance of a healthcare professional and may involve a combination of these treatments. 3 4

From the Research

Initial Management of Rheumatoid Arthritis in the ED

The initial management of rheumatoid arthritis (RA) in the emergency department (ED) involves a comprehensive approach to reduce inflammation, slow disease progression, and manage symptoms.

• Nonpharmacologic therapy includes rest, occupational and physical therapy, weight reduction, and the use of assistive devices as necessary 5.
• Pharmacologic options for RA management include:
  • Nonsteroidal anti-inflammatory drugs (NSAIDs) to reduce inflammation and pain
  • Corticosteroids to reduce inflammation and slow disease progression
  • Disease-modifying antirheumatic drugs (DMARDs) to slow disease progression
  • Antitumor necrosis factor agents and interleukin receptor antagonists to reduce inflammation and slow disease progression 5

Safety of NSAIDs in RA Management

The safety of NSAIDs in RA management has been evaluated in several studies.

• A systematic review and network meta-analysis found that naproxen 1,000 mg/day improved physical function, reduced pain, and decreased the number of painful joints compared to placebo 6.
• Another study found that celecoxib had a similar or lower risk of cardiovascular, gastrointestinal, and renal adverse events compared to ibuprofen and naproxen in patients with RA 7.
• However, the use of anti-inflammatory doses of aspirin should be avoided due to potential adverse effects on liver and renal function 8.

Treatment Guidelines

The American College of Rheumatology published guidelines for the treatment of rheumatoid arthritis in 2015, with an update expected in late 2019/early 2020 5.

• These guidelines recommend a multidisciplinary approach to RA management, including nonpharmacologic and pharmacologic therapies.
• The guidelines also emphasize the importance of early and accurate diagnosis, as well as optimal personalized treatment to achieve better outcomes for RA patients 9.