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Posts: 841
Joined: 24 Mar 2013 01:28
Full Name: Govind Mohan
Name of Your College/Medical School: Madras Medical College


Post by gmohan »

Rheumatoid Arthritis: A Protocol for Early Referral and DMARD Monitoring Guidelines

Rheumatoid arthritis (RA) continues to offer a major management challenge: patients often present with non-specific, atypical symptoms.
The diagnosis often cannot be confirmed or refuted with diagnostic tests, hence diagnosis is difficult. Other factors that might delay diagnosis include a lack of specialist clinics and rheumatologists.

A major step forward in the past ten years has been the realisation that early treatment with disease-modifying anti-rheumatic drugs (DMARDs) is important if the disease process is to be slowed or halted.
The rationale behind the early initiation of disease-modifying agents in RA is based on the recognition that joint damage occurs most rapidly early in the disease.
Early referral is essential to reduce the inflammatory course and thus reduce the potential for joint damage.
Referral to specialist clinics also enables patients to benefit from a holistic approach to the disease facilitated by the multidisciplinary team.

Management goals

Relief of symptoms
Preservation of function
Prevention of structural damage and deformity
Patient education
Maintenance of patient's normal lifestyle

Making a diagnosis

Complete history and clinical examination/assessment of symptoms

Morning stiffness, fatigue
Synovitis of three or more joint areas
Symmetric arthritis


The pattern of joint involvement almost always favours the MCP and PIP joints/wrists
The swelling on palpation is characteristic. Synovial swelling is soft unlike the hard, bony swelling in diseases like OA

Differential diagnosis

Other inflammatory arthritis, e.g. post viral
Non-inflammatory joint conditions
Connective tissue diseases
Other important diagnoses, e.g. polymyalgic rheumatica


Full blood count
Rheumatoid factor
X-ray hands/feet (not necessary before referral)

Dr G Mohan.

If needed : Referral to Specialist-why,when and how ?
Pharmacoligical approach?

Can be requested from the author.
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