What is the best initial management approach for a patient with suspected new onset rheumatoid arthritis (RA) presenting to the emergency room?

Emergency Management of Suspected New Onset Rheumatoid Arthritis

Immediately refer the patient to a rheumatologist for evaluation within 6 weeks of symptom onset while initiating symptomatic treatment in the emergency department, as early DMARD therapy (ideally within 3 months) prevents irreversible joint damage in up to 90% of patients. 1, 2

Immediate ED Assessment and Documentation

Perform a focused clinical examination to identify definite synovitis (joint swelling), as this is the cornerstone of RA diagnosis and the method of choice for detecting arthritis. 1, 3

Key examination findings to document:

• 28-joint count assessment examining metacarpophalangeal joints (MCPs), proximal interphalangeal joints (PIPs), wrists, elbows, shoulders, and knees for tenderness and swelling 4
• Morning stiffness duration (>30 minutes suggests inflammatory arthritis; >1 hour is typical for RA) 1, 5
• Symmetric small joint involvement pattern (MCPs, PIPs, wrists, metatarsophalangeal joints are characteristic) 4, 5
• Squeeze test of MCPs and metatarsophalangeal joints to assess for clinical synovitis 4
• Skin examination for psoriatic plaques or nail changes to exclude psoriatic arthritis 4

Critical pitfall: Distal interphalangeal joints are typically spared in RA—if these are prominently involved, consider alternative diagnoses like psoriatic arthritis or osteoarthritis. 4

Essential Laboratory Testing from the ED

Order the following tests immediately to facilitate rheumatology evaluation:

Autoimmune serology panel:

• Rheumatoid factor (RF) - sensitivity 60%, specificity 70% 4, 3
• Anti-citrullinated protein antibodies (ACPA/anti-CCP) - sensitivity 60%, specificity 90% 4, 3

Inflammatory markers:

• C-reactive protein (CRP) - preferred over ESR as it is more reliable and not age-dependent 4, 3
• Erythrocyte sedimentation rate (ESR) 1

Baseline laboratory assessment:

• Complete blood count with differential (assess for cytopenias before treatment) 4, 3
• Comprehensive metabolic panel including liver function tests, renal function, glucose 4
• Urinalysis 1, 4

Conditional testing based on presentation:

• Antinuclear antibodies (ANA) if diagnosis uncertain to screen for lupus or other connective tissue diseases 4, 3
• HLA-B27 if axial or entheseal involvement suggests spondyloarthropathy 4
• Hepatitis B, Hepatitis C, and tuberculosis screening (required before any biologic therapy) 4

Critical pitfall: Never dismiss RA diagnosis based on negative RF or normal inflammatory markers—20-30% of RA cases are seronegative, and acute phase reactants can be normal even in active disease. 4

Imaging Studies to Order

Baseline radiographs:

• Bilateral hand, wrist, and foot X-rays to assess for erosions, which predict RA diagnosis and disease persistence 4, 3
• Radiographic findings in early disease: soft tissue swelling, juxtaarticular osteoporosis, and potentially early erosions 5

Advanced imaging if diagnosis uncertain:

• Ultrasound with Power Doppler detects synovitis 2.18-fold more frequently than clinical examination and can identify subclinical inflammation 3
• MRI with IV contrast is more sensitive than ultrasound in early stages and detects bone marrow edema (osteitis), the best single predictor of future disease progression 4, 3

Symptomatic Treatment Initiated from the ED

NSAIDs for symptomatic relief:

• Naproxen 500 mg twice daily (or equivalent NSAID) at the minimum effective dose for the shortest time possible 1, 6
• Assess gastrointestinal, renal, and cardiovascular risks before prescribing 1
• Onset of pain relief begins within 1 hour for naproxen, with analgesic effect lasting up to 12 hours 6

Short-term glucocorticoids as bridge therapy:

• Prednisone 5-10 mg daily for temporary relief (<6 months) while awaiting DMARD effect 1, 7, 8
• Systemic glucocorticoids reduce pain, swelling, and structural progression but must be used at the lowest dose necessary due to cumulative side effects 1
• Intra-articular glucocorticoid injections can be considered for localized joint inflammation 1, 7

Critical pitfall: Never use corticosteroid monotherapy long-term—steroids must be combined with DMARDs for disease modification, as they do not prevent joint damage when used alone. 7

Urgent Rheumatology Referral Criteria

Refer within 6 weeks if:

• Any joint swelling associated with pain or stiffness 1, 3
• Small joints of hands/feet affected 3
• More than one joint involved 3
• Delay of 3 months or longer between symptom onset and seeking medical advice 3

The 3-month window is critical: Patients at risk of persistent arthritis should be started on DMARDs as early as possible (ideally within 3 months), even if they do not fulfill classification criteria for RA, as this is the "window of opportunity" to prevent irreversible joint damage. 1, 7, 9

Risk Stratification for Persistent/Erosive Disease

Document the following prognostic factors to guide rheumatology management decisions:

• Number of swollen and tender joints 1
• Elevated acute phase reactants (CRP/ESR) 1
• Positive rheumatoid factor 1
• Positive ACPA antibodies 1
• Presence of erosions on baseline radiographs 1, 4

Patients with multiple poor prognostic factors require aggressive early treatment with methotrexate 15-25 mg weekly, with rapid escalation to biologic DMARDs if remission is not achieved within 3 months. 7, 2

ED Discharge Instructions and Follow-up

Provide patient education on:

• The importance of urgent rheumatology follow-up within 6 weeks 1, 3
• Expected morning stiffness and joint symptoms 5
• Smoking cessation (smoking is a modifiable predictor of adverse outcomes) 1, 7
• Return precautions for worsening symptoms, fever, or inability to perform activities of daily living 5

Ensure rheumatology appointment is scheduled before discharge with all laboratory results and imaging studies forwarded to the specialist. 1

Critical pitfall: Never delay DMARD initiation waiting for definitive classification criteria to be met—early treatment within 3 months prevents irreversible joint damage and improves long-term outcomes in up to 90% of patients. 7, 2