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Rheumatoid arthritis - Management
Basis for recommendation

Specialist advice

  • Specialist advice or referral is recommended for a flare of rheumatoid arthritis:
    • For an intra-articular corticosteroid injection (in the absence of the expertise to do this in primary care).
    • To organize an early follow-up appointment to titrate the person's disease-modifying anti-rheumatic drugs (DMARDs). See the CKS topic on DMARDs.

Corticosteroids

  • The National Institute for Health and Clinical Excellence (NICE) recommends that corticosteroids should be used to treat a flare of RA, but gives no preference on the type of corticosteroid, or on the route of administration [NICE, 2009].
  • An intramuscular corticosteroid will allow control of dosage, and is preferred to an oral corticosteroid [SIGN, 2004]. The choice of intra-articular corticosteroid is based on feedback from CKS expert reviewers. Triamcinolone is not recommended for small joints because of the risk of extra-articular extravasation and soft tissue atrophy. Lidocaine is not recommended for injection into small joints with hydrocortisone because there is not enough room in the intra-articular space for both.
  • The use of corticosteroids to treat flares of RA is not based on trial evidence. NICE recognizes that this practice is common and is seen to be beneficial, and therefore recommends the use of corticosteroids for the treatment of flares [National Collaborating Centre for Chronic Conditions, 2009]. The dose of oral corticosteroids for a flare is based on feedback from CKS expert reviewers.
  • The long-term adverse effects of corticosteroid use are a cause for concern, and there is conflicting evidence on the disease-modifying effects of corticosteroids taken in the long term (for example 2 years) [Kirwan, 1995; Capell et al, 2004; NICE, 2009].

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