Arthritis Flares (of Rheumatoid/Psoriatic) - Management Guidance

Referring to secondary care

Please contact orthopaedics on call if you have concerns re septic arthritis.
If you have issues with settling a flare then please contact rheumatology on call.

Background

In patients who have an established diagnosis of Rheumatoid or Psoriatic Arthritis (RA/PsA), flare ups of the disease may still happen despite being on disease modifying anti-rheumatic drugs (DMARDs).

Recognising a flare up

History

Is there any significant early morning stiffness (>30 minutes)?
How many joints are affected?
Is the joint(s) swollen?

Examine for any joint swelling and tenderness
Be aware that patients with RA/PsA can have other diagnoses that may contribute to pain eg.osteoarthritis, fibromyalgia, carpal tunnel syndrome and trauma.

If only one joint is affected, hot/red and acute (less than 3 days) onset with a patient who is systemically unwell, septic arthritis should be excluded by checking temperature, CRP and WCC.

Patients can also present with flare ups of RA in other ways, for example general symptoms such as fatigue, weight loss and anaemia. In these situations the usual causes need to be excluded.

Investigations to aid diagnosis and exclude other causes

FBC
Haematinics
Thyroid function
Inflammatory markers (CRP) can be helpful if in doubt whether pain is from RA/PsA flare or other causes, but you must ensure there are no other reasons for raised inflammatory markers (infection, known malignant processes, or other inflammatory processes)
Other tests such as CXR, abdominal USS, CT, Echocardiogram or GI investigations could be considered depending on clinical situation.

Management

Rest the joint and apply cold compress
Non steroidal anti-inflammatories (NSAIDs) if no contraindications. Co-administer gastric protection
Appropriate analgesia
Steroids

1^st line (due to lower cumulative steroid dose): intramuscular eg Kenalog 80mg (any weight) or Depomedrone (80mg for a patient weighing <60kg or 120mg if weighing >60kg). Caution in patients on anti-coagulation or those with clotting abnormalities
2^nd line: oral in reducing course. A typical short course would be Prednisolone 20mg reducing by 5mg every 5 days. Co-administer gastric protection
Intra-articular: If no contraindications and trained and confident, an intra-articular steroid injection can be given into the affected joint if 1 or 2 joints are involved.