What is the best course of treatment if I suspect I have rheumatoid arthritis?

Immediate Referral to a Rheumatologist is Essential

If you suspect rheumatoid arthritis, you must see a rheumatologist urgently—within 1-2 weeks—for definitive diagnosis and immediate initiation of disease-modifying antirheumatic drugs (DMARDs), as delays in treatment lead to irreversible joint damage and permanent disability. 1

Why Urgent Rheumatology Referral is Critical

• Rheumatologists are the specialists who should primarily care for RA patients, as they diagnose earlier, prescribe DMARDs more frequently, and achieve better outcomes including less joint damage and better physical function compared to other physicians 1
• Early treatment with DMARDs prevents permanent disability: 20-30% of untreated RA patients become permanently work-disabled within 2-3 years of diagnosis 2
• Complications begin within months of presentation, making early referral for DMARD initiation essential 2
• Treatment should start as soon as the diagnosis is made—do not wait for extensive testing or symptom progression 1

What to Expect at Your Rheumatology Appointment

Diagnostic Confirmation

Your rheumatologist will confirm the diagnosis using:

• Clinical examination for joint swelling: At least one joint with definite swelling not explained by another disease 1, 3
• Blood tests: Rheumatoid factor (RF), anti-citrullinated protein antibodies (ACPA), C-reactive protein (CRP), and erythrocyte sedimentation rate (ESR) 1, 3
• Joint assessment: 28-joint count including proximal interphalangeal joints, metacarpophalangeal joints, wrists, elbows, shoulders, and knees 1
• Disease activity scoring: Using SDAI (Simplified Disease Activity Index) or CDAI (Clinical Disease Activity Index) 1

Important caveat: No single laboratory test is diagnostic—RA is primarily a clinical diagnosis 2

First-Line Treatment: Methotrexate

Methotrexate (MTX) should be part of your first treatment strategy and will be started immediately upon diagnosis 1

Standard Methotrexate Protocol

• Starting dose: 15-25 mg weekly (oral or subcutaneous), optimized to maximally tolerated dose 1, 4
• Folic acid supplementation: Always given with methotrexate to reduce side effects 5
• Combination therapy: Other medications (NSAIDs, low-dose corticosteroids) may be continued during MTX treatment 1, 4

If Methotrexate Cannot Be Used

If you have contraindications or early intolerance to MTX:

• Alternative first-line DMARDs: Sulfasalazine (SSZ) or leflunomide should be considered 1

Corticosteroid Bridge Therapy

Low-dose glucocorticoids (prednisone) should be added to your initial DMARD strategy for up to 6 months, then tapered as rapidly as clinically feasible 1

• This provides symptom relief while waiting for DMARDs to take full effect
• After 1-2 years, long-term corticosteroid risks (cataracts, osteoporosis, fractures, cardiovascular disease) outweigh benefits 1

Treatment Goals and Monitoring Schedule

Target: Remission or Low Disease Activity

• Primary goal: Clinical remission (SDAI ≤3.3 or CDAI ≤2.8) 1
• Acceptable alternative: Low disease activity (SDAI ≤11 or CDAI ≤10) 1
• Treatment decisions must be based on shared decision-making between you and your rheumatologist 1

Aggressive Monitoring Timeline

• Every 1-3 months during active disease 1, 6
• 3-month checkpoint: If no improvement, therapy must be adjusted 1
• 6-month checkpoint: If target not reached, therapy must be adjusted 1
• Any new treatment should be tried for at least 3-6 months to fully assess efficacy 1

Treatment Escalation Algorithm

At 3 Months: If Not Improving on MTX + Prednisone

If you have low to moderate disease activity (SDAI >11 or CDAI >10) at 3 months 1:

• Add sulfasalazine + hydroxychloroquine for triple-DMARD therapy, OR
• Switch to subcutaneous MTX if on oral, OR
• Add a biologic DMARD (TNF inhibitor or abatacept) 1

If you have high disease activity (SDAI ≥26 or CDAI ≥22) at 3 months 1:

• Biologic DMARDs are required: TNF inhibitors (adalimumab, etanercept, infliximab, golimumab, certolizumab) or abatacept 1, 7
• These are combined with MTX, not used as monotherapy 1

At 6-12 Months: If Target Still Not Achieved

If SDAI >11 (CDAI >10) at 6-12 months 1:

On MTX monotherapy:

• Add SSZ + hydroxychloroquine (triple-DMARD), OR
• Add TNF inhibitor, OR
• Add abatacept 1

Already on MTX + biologic:

• Switch to alternative biologic with different mechanism of action 1
• Options include: tocilizumab (anti-IL-6), rituximab (anti-CD20), or alternative TNF inhibitor 1, 6

Beyond First Year: Persistent Active Disease

For moderate/high disease activity (SDAI >11 or CDAI >10) beyond 1 year 1:

On DMARD-only therapy:

• Initiate triple-DMARD therapy (MTX + SSZ + hydroxychloroquine) 1

On biologic therapy:

• Switch to alternative biologic with different mechanism of action 1
• After inadequate response to TNF inhibitor: consider abatacept, tocilizumab, or rituximab 1
• Tofacitinib may be considered after biologic treatment has failed 1

Biomarker guidance: If seronegative for RF and inadequate response to anti-TNF drugs, prefer abatacept or tocilizumab over rituximab 1

Critical Pitfalls to Avoid

• Do not delay referral: Every week of delay allows irreversible joint damage 1, 2
• Do not accept "watchful waiting": RA requires immediate DMARD therapy 1, 8
• Do not rely solely on symptom relief: NSAIDs and corticosteroids alone do not prevent joint destruction 9
• Do not skip monitoring appointments: Frequent assessment is essential to prevent progression 1, 6
• Do not assume fibromyalgia or central pain: High tender joint counts without swelling or elevated inflammatory markers require investigation, not automatic treatment escalation 1

Long-Term Outlook

• Remission is achievable: With treat-to-target strategies and early aggressive treatment, remission is realistic and achievable 1
• Drug-free remission possible: 15-25% of patients achieving sustained remission may successfully taper therapy 1
• Patients not achieving remission by 1 year experience substantially higher rates of joint erosion progression over the following decade 1