Tasty Morsels of EM 050 – Rheumatoid arthritis

12 May

As always, this is from the ever expanding google doc on bits and bobs I read and learn from and transfer here for all our learning pleasure. Some of this morsel is straight advice from a local rheumatologist rather than strict EBM.

  • commonest presentation
    • middle aged female with multiple small joints
    • remember that if symptoms less than 6 weeks then it’s usually one of many viruses
  • there are formal diagnostic criteria
    • heavily weighted on number of joints involved and some of the tests
    • >6 weeks duration is on the criteria
  • 10% of healthy population has pos rheumatoid factor.
  • Swollen joint much more diagnostically useful than simple painful joint
  • anti CCP the big new test. Very specific test but not sensitive
  • Rheumatoid in general carries increased CV risk never mind the NSAID use

Treatment pearls

  • flare of known RA
    • steroids depomedrone 80mg IM or 40mg oral for a week
    • NSAIDs – remember naproxen is the only one with low CV risk
  • mouth ulcers on methotrexate?
    • change to nightly dose
    • double up on folic acid dose
  • abnormal LFT on methotrexate?
    • ALT is usually first to rise, if continuing to rise at 2 weeks consider stopping
  • abnormal FBC on methotrexate?
    • neuts <1.5 then stop drug.
    • it was suggested that MTX be held in all infections needing antibiotics even when WCC is normal
  • Long term steroids are rarely appropriate any more – if you find someone floating around on long term steroids from 15 yrs ago the they’ve probably been lost to follow up and it’s worth referring them again.



  • Excellent rheumatology lecture somewhere in the midlands of Ireland Spring 2015
  • Rosen’s 8th Chap 116

Featured Image: James Heliman MD, CC License, Wikipedia

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