What is the initial management for a patient with multiple joint swelling and pain over the hand, suspected of having inflammatory arthritis such as rheumatoid arthritis?

Initial Management of Multiple Joint Swelling and Pain in the Hand

When a patient presents with multiple joint swelling and pain over the hand, immediately perform clinical examination to detect synovitis, obtain inflammatory markers (CRP/ESR), rheumatoid factor, anti-citrullinated peptide antibodies (ACPA), complete blood count, liver and renal function tests, and refer to rheumatology within 6 weeks if inflammatory arthritis is suspected. 1

Immediate Clinical Assessment

Confirm true synovitis versus arthralgia:

• Perform a "squeeze test" across the metacarpophalangeal (MCP) joints to detect small joint synovitis 1
• Document palpable joint swelling with tenderness—this indicates inflammatory arthritis, not just pain 1, 2
• Assess morning stiffness duration: >30 minutes strongly suggests inflammatory arthritis rather than osteoarthritis 1, 2
• Examine for symmetric small joint involvement, which is characteristic of rheumatoid arthritis 3, 4, 5

Critical pitfall: Do not code or treat as simple arthralgia if true synovitis is present on examination—this represents inflammatory arthritis requiring urgent workup and rheumatology referral 6

Essential Laboratory Workup

Obtain the following tests immediately:

• C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) for diagnostic and prognostic information 1
• Rheumatoid factor (RF) and anti-citrullinated peptide antibodies (ACPA)—these have both diagnostic and prognostic value 1, 3, 4
• Complete blood count to identify systemic inflammation and exclude infection or malignancy 1
• Liver function tests (transaminases) and renal function tests to establish baseline before initiating disease-modifying therapy 1
• Urinalysis to identify renal involvement 1
• Antinuclear antibodies (ANA) to screen for systemic lupus erythematosus and other connective tissue diseases 1

Important note: Do not delay referral or treatment waiting for positive serology—20-30% of rheumatoid arthritis cases are seronegative, and early treatment prevents irreversible joint damage 6

Imaging Studies

Obtain baseline radiographs:

• Plain x-rays of both hands to evaluate for erosions, joint damage, or baseline structural changes 1
• Baseline radiographs are essential for monitoring structural progression over time 1

Consider ultrasound with power Doppler:

• This is the preferred confirmatory test when clinical examination is uncertain about the presence of synovitis 1, 2
• Ultrasound detects synovitis 2.18-fold more frequently than clinical examination in hands and wrists 2
• Power Doppler can detect active inflammation even when joints appear clinically normal 2

Risk Stratification for Persistent Disease

Assess the following prognostic factors to identify high-risk patients:

• Number of swollen and tender joints 1
• Elevated acute phase reactants (ESR/CRP) 1
• Presence of RF and ACPA 1
• Radiographic erosions on baseline imaging 1

These factors help identify patients at high risk of persistent arthritis who require aggressive early treatment 1

Immediate Symptomatic Management

Initiate NSAIDs for symptom control:

• Use NSAIDs at the minimum effective dose for the shortest duration after evaluating gastrointestinal, renal, and cardiovascular risks 1
• Naproxen has been shown to reduce joint swelling, morning stiffness, and disease activity in rheumatoid arthritis patients 7
• NSAIDs control pain and inflammation but do not slow disease progression 8

Consider intra-articular corticosteroid injections:

• These can be used for large joint oligoarthritis, but only after infection is excluded 1

Critical warning: Do not rely on NSAIDs alone—they provide symptomatic relief but do not prevent joint damage 8

Urgent Rheumatology Referral

Refer to rheumatology within 6 weeks for:

• Any patient with polyarticular swelling 1, 2
• Positive inflammatory markers 1
• Suspected inflammatory arthritis 1

Immediate referral (within days) if:

• Joint swelling (synovitis) persists >4 weeks 1
• Signs of erosive disease on imaging 1

Disease-Modifying Therapy Initiation

Start methotrexate within 3 months in patients at risk of persistent arthritis:

• Methotrexate is the first-line disease-modifying antirheumatic drug (DMARD) for rheumatoid arthritis 9, 3, 10, 4, 8
• Recommended starting dose for rheumatoid arthritis: 7.5 mg once weekly orally, or divided doses of 2.5 mg at 12-hour intervals for 3 doses given once weekly 9
• Administer with folic acid to reduce side effects 10
• Therapeutic response usually begins within 3-6 weeks, with continued improvement for up to 12 weeks 9

Escalate treatment if inadequate response:

• Add additional DMARDs or biologic agents if disease activity persists despite methotrexate monotherapy 1, 10, 4
• Biologic agents (TNF inhibitors, rituximab, abatacept) are generally considered second-line or can be added for dual therapy 4, 8

Before initiating DMARDs or biologics:

• Test for hepatitis B, hepatitis C, and tuberculosis 3, 4

Monitoring Disease Activity

Serial monitoring at 1-3 month intervals using:

• Tender and swollen joint counts 1
• Patient and physician global assessments 1
• Inflammatory markers (CRP/ESR) 1

Treatment goal: Achieve disease remission or the lowest disease activity possible through a treat-to-target strategy 3, 10

Key Distinctions from Osteoarthritis

The provided evidence includes osteoarthritis guidelines 11, but these are not applicable to inflammatory arthritis suspected in this clinical scenario. The critical distinguishing features are:

• Morning stiffness >30 minutes (inflammatory) versus brief stiffness (osteoarthritis) 1, 2
• Symmetric small joint involvement with palpable synovitis (inflammatory) versus asymmetric large joint involvement (osteoarthritis) 3, 5
• Elevated inflammatory markers (inflammatory) versus normal markers (osteoarthritis) 1