What is the best course of action for a patient with a history of Rheumatoid Arthritis (RA) experiencing bilateral ankle and foot pain and swelling that worsens throughout the day?

Bilateral Ankle and Foot Pain in Established RA: Urgent Rheumatology Referral and Treatment Escalation Required

This patient with established RA presenting with new bilateral ankle and foot involvement worsening throughout the day requires immediate rheumatology referral and aggressive treatment escalation, as this represents active inflammatory disease that will lead to irreversible joint damage without prompt intervention. 1, 2

Immediate Assessment and Referral

• Refer to rheumatology urgently - patients with arthritis involving more than one joint should be seen by a rheumatologist ideally within 6 weeks, though this patient with established RA may need even faster access 1
• The bilateral ankle and foot involvement with diurnal worsening (worse as day progresses) is highly characteristic of inflammatory arthritis, particularly RA progression 1, 3
• A positive "squeeze test" of the metatarsophalangeal joints would confirm inflammatory involvement of the feet 1

Disease Activity Assessment Required

Quantitative disease activity measurement is essential before treatment decisions:

• Perform 28-joint count assessment including swollen and tender joint counts 2, 4
• Measure inflammatory markers: C-reactive protein (CRP) is preferred over ESR as it's more reliable and not age-dependent 4
• Calculate composite disease activity score using DAS28, SDAI, or CDAI 1, 2, 5
• Assess patient global assessment and functional status 4

Treatment Escalation Strategy

The primary treatment goal is achieving remission (SDAI ≤3.3) or low disease activity (SDAI ≤11): 1, 2, 4

If Not Currently on DMARDs:

• Start methotrexate immediately as the anchor drug, typically 15-25 mg weekly (oral or subcutaneous) with folic acid supplementation 1, 2, 6
• Subcutaneous methotrexate has better bioavailability than oral administration in patients with inadequate response 5

If Already on Methotrexate Monotherapy:

• Optimize methotrexate dose to 20-25 mg weekly or maximum tolerated dose first 5, 6
• Consider switching to subcutaneous administration if on oral formulation 5
• If inadequate response after 3 months, add biologic DMARD (TNF inhibitor such as adalimumab, etanercept, or infliximab) or consider triple DMARD therapy 1, 4, 7

If Already on Combination Therapy:

• Switch to different biologic agent with alternative mechanism of action if current regimen failing 1, 2
• Consider rituximab if patient is seropositive for RF/anti-CCP 5

Adjunctive Symptomatic Management

Short-term glucocorticoids should be added during treatment escalation:

• Systemic glucocorticoids (prednisone 10-20 mg daily) reduce pain and swelling as adjunctive therapy 1
• Intra-articular glucocorticoid injections should be considered for the affected ankle joints for rapid local symptom relief 1
• Glucocorticoids should be tapered as rapidly as clinically feasible, ideally within weeks to months 1, 2

NSAIDs for symptomatic relief:

• NSAIDs may be used after evaluating gastrointestinal, renal, and cardiovascular status 1
• Naproxen has been shown effective for reducing joint pain, swelling, and improving mobility in RA 8

Monitoring and Treatment Adjustment

Frequent monitoring is mandatory with treat-to-target approach:

• Reassess disease activity every 1-3 months during active disease 1, 2
• If no improvement by 3 months or target not reached by 6 months, therapy must be adjusted 1, 2
• The goal is sustained remission or low disease activity 1, 2

Baseline Investigations Before Treatment Changes

Before escalating to biologic therapy, obtain:

• Complete blood count, liver function tests, renal function, urinalysis 1
• Screen for hepatitis B, hepatitis C, and tuberculosis before starting biologic agents 4, 3
• Baseline radiographs of hands, wrists, and feet to document structural damage 4, 5
• RF and anti-CCP antibodies if not previously tested 1, 2

Critical Pitfalls to Avoid

• Do not delay treatment escalation - waiting leads to irreversible joint damage and disability 1, 6
• Do not rely solely on patient symptoms without objective disease activity measures, as central pain amplification can coexist with active inflammation 1
• Do not continue ineffective therapy beyond 3-6 months - this violates treat-to-target principles 1, 2
• Do not use long-term corticosteroids as monotherapy - after 1-2 years, risks (osteoporosis, fractures, cardiovascular disease) outweigh benefits 1

Non-Pharmacological Interventions

Adjunctive therapies should be incorporated:

• Dynamic exercises and occupational therapy to maintain function 1
• Footwear modifications and orthoses for biomechanical support 9, 10
• Patient education about disease management and treatment goals 1