Patient handout

Rheumatoid arthritis

PRODUCTION

1. Your condition

This handout is for rheumatoid arthritis. Your care team identified this based on: symmetric small-joint polyarthritis (mcp/pip/wrist) + morning stiffness >30–60 min (2010 acr/eular aletaha).

Other reasons your team may use this plan: positive rf and/or anti-ccp/acpa with joint symptoms (2010 acr/eular aletaha); elevated esr/crp with inflammatory arthralgia pattern (eular 2023 smolen); established ra — treat-to-target titration / disease-activity visit (acr 2021 fraenkel; eular 2023 smolen).

2. Your medications

Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.

Medication	Starting dose	How	When	What it does
methotrexate	15 mg PO/SC weekly, titrate to 20–25 mg/wk over 4–6 wk	PO/SC	once weekly	ACR 2021 Fraenkel / EULAR 2023 Smolen — MTX is the anchor csDMARD; switch PO→SC if GI intolerance or inadequate response before declaring failure
folic acid	5 mg PO weekly (≥24 h after MTX) or 1 mg daily	PO	weekly or daily	Mandatory with MTX to reduce stomatitis, GI and hepatic toxicity (ACR 2021 Fraenkel)
prednisone	≤7.5–10 mg/day PO (lowest effective), rapid taper off within ≤3 months	PO	once daily	EULAR 2023 Smolen — short-term low-dose bridge while csDMARD takes effect; lowest dose, shortest duration, tapered — chronic glucocorticoids to be avoided
sulfasalazine	500 mg PO BID, titrate to 1 g BID	PO	BID	ACR 2021 Fraenkel — csDMARD alternative when MTX contraindicated; pregnancy-compatible
hydroxychloroquine	≤5 mg/kg/day PO (typically 200–400 mg/day)	PO	once daily	ACR 2021 Fraenkel — mild disease / triple-therapy component; pregnancy-compatible; baseline + annual retinal screen

Plan: RA treat-to-target DMARD ladder (csDMARD anchor → bDMARD/tsDMARD by target → triple-therapy alt → taper in remission)

3. When to call your provider

Contact your care team if any of the following happen:

Hot/disproportionately painful single RA joint + fever → ED for STAT arthrocentesis (superimposed septic arthritis) (EULAR 2023 Smolen)
New dyspnea/cough/hypoxia on MTX → hold MTX, urgent HRCT (MTX pneumonitis vs RA-ILD) (ACR 2021 Fraenkel)
Fever/serious infection on biologic/JAKi → hold immunosuppression, urgent evaluation (ACR 2021 Fraenkel)
New neurologic deficit / gait change → urgent cervical-spine MRI (cervical myelopathy) (EULAR 2023 Smolen)

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

Acutely hot, disproportionately painful single joint on an RA background ± fever / immunosuppression (EULAR 2023 Smolen)(life-threatening)
New dyspnea, dry cough, hypoxia, diffuse infiltrates on methotrexate (ACR 2021 Fraenkel)(life-threatening)
Fever / sepsis / reactivated TB or HBV on a TNFi/biologic/JAKi (ACR 2021 Fraenkel; EULAR 2023 Smolen)(life-threatening)
Progressive limb weakness, gait change, Lhermitte sign, or atlanto-axial instability — pre-intubation airway risk (EULAR 2023 Smolen)(life-threatening)
DAS28-CRP >5.1 (or CDAI/SDAI high) persisting despite optimised csDMARD at 3–6 months + poor-prognosis markers (ACR 2021 Fraenkel; EULAR 2023 Smolen)
JAKi considered in age >65 / established CV disease / current-or-former smoker / malignancy history (ORAL Surveillance Ytterberg NEJM 2022)
Pregnancy or conception planned while on methotrexate or leflunomide (EULAR 2023 Smolen; ACR 2020 reproductive)

5. Follow-up

Lifelong rheumatology follow-up; treat-to-target re-titration, taper in sustained remission, vaccination maintenance (avoid live vaccines on biologics/JAKi), aggressive lipid/BP/smoking CV modification, bone health, PT/OT + functional assessment, pre-conception planning, surgical referral for joint destruction (ACR 2021 Fraenkel; EULAR 2023 Smolen)

6. Sources

Guideline: 2021 ACR RA Treatment Guideline + 2022/2023 EULAR RA management recommendations; 2010 ACR/EULAR classification