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Rheumatoid arthritis - Management
How should I manage a flare of rheumatoid arthritis?

  • Exclude septic arthritis (suspect this if a single joint is hot and swollen, especially if there are signs of sepsis).
  • Suspect a flare of rheumatoid arthritis (RA) if there is worsening:
    • Symptoms of stiffness, pain, joint swelling, or general fatigue.
    • Signs of joint synovitis, joint tenderness, or loss of joint function.
    • Inflammatory markers. For example, an increase in C-reactive protein from previous levels.
  • Consider other causes for worsening symptoms such as joint damage, where referring to an orthopaedic surgeon may be more appropriate.
  • Seek specialist advice about management. For immediate control of symptoms, consider:
    • A nonsteroidal anti-inflammatory drug (NSAID) plus paracetamol, or an NSAID plus paracetamol plus codeine.
      • In people at risk of cardiovascular adverse events, ibuprofen up to 1200 mg per day or naproxen up to 1000 mg per day are recommended as first-line NSAID options.
    • An intra-articular corticosteroid injection for a localized RA flare, if the expertise is available in primary care.
      • For large or medium-size joints: use methylprednisolone or triamcinolone mixed with lidocaine.
      • For small joints: use methylprednisolone (ready-mixed with lidocaine) or hydrocortisone.
    • An intramuscular corticosteroid, if an intra-articular corticosteroid is not possible or appropriate.
      • If it is not practical to give an intramuscular corticosteroid, a 2–4 week reducing course of an oral corticosteroid can be started whilst awaiting specialist assessment.
      • For more information on drug doses, see Prescriptions.
      • Do not start long-term corticosteroids before seeking specialist advice.

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