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rheum.rheumatoid-arthritis.core.v1PRODUCTION
rheum.rheumatoid-arthritis.core.v1

Rheumatoid arthritis

rheumatologychronicadult
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Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Adult chronic autoimmune symmetric inflammatory polyarthritis; scope = early + established RA, seropositive vs seronegative, treat-to-target with composite disease activity (ACR 2021 Fraenkel; EULAR 2023 Smolen)

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RA scope confirmed (not crystal / spondyloarthritis / connective-tissue mimic)

Patient inputs (15)

Age >65 (or CV/cancer risk) is a JAKi boxed-warning modifier (ORAL Surveillance Ytterberg NEJM 2022); informs frailty + DMARD choice

Methotrexate + leflunomide CONTRAINDICATED in pregnancy/conception — washout; certolizumab/HCQ/sulfasalazine/low-dose prednisone compatible (EULAR 2023 Smolen; ACR 2020 reproductive health)

Symptom duration ≥6 weeks is a 2010 classification axis and defines early vs established RA window (Aletaha 2010)

Accelerated ASCVD is the leading cause of death in RA; mandates aggressive CV risk modification + IL-6/JAKi lipid monitoring (EULAR 2022 CV risk; ORAL Surveillance Ytterberg NEJM 2022)

Current csDMARD/bDMARD/tsDMARD + glucocorticoid dose/duration drives add-vs-switch and perioperative hold logic (ACR 2021 Fraenkel; ACR/AAHKS 2022 perioperative)

Inflammatory stiffness >30–60 min distinguishes RA from osteoarthritis (2010 ACR/EULAR Aletaha)

Tender/swollen joint count + small-joint symmetric pattern drives 2010 ACR/EULAR classification and DAS28/CDAI/SDAI

RF positivity (low vs high titre) scores 2010 criteria and is a poor-prognosis marker (Aletaha 2010; EULAR 2023 Smolen)

Anti-CCP/ACPA is the most specific RA antibody and a strong poor-prognosis / erosive marker (Aletaha 2010; EULAR 2023 Smolen)

Acute-phase reactant scores classification, drives DAS28-CRP / CDAI / SDAI treat-to-target composite (ACR 2021 Fraenkel)

HBsAg/anti-HBc + HCV mandatory before immunosuppression — biologic/JAKi can reactivate HBV (EULAR 2023 Smolen; ACR 2021 Fraenkel)

Latent TB (IGRA) screen mandatory before TNFi/biologic/JAKi — treat LTBI ≥1 month before start (ACR 2021 Fraenkel; EULAR 2023 Smolen)

ILD, rheumatoid nodules, vasculitis, Felty, secondary Sjögren, scleritis change drug selection + monitoring (EULAR 2023 Smolen)

Alternate acute-phase reactant for classification + DAS28-ESR; discordance vs CRP informs IL-6 therapy interpretation

Atlanto-axial instability / cervical myelopathy — pre-operative C-spine flexion-extension imaging before intubation (EULAR 2023 Smolen)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (7)

7 need judgement
  • informationallife_threateningseptic_arthritis_on_ra_joint
    Acutely hot, disproportionately painful single joint on an RA background ± fever / immunosuppression (EULAR 2023 Smolen)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningmtx_pneumonitis
    New dyspnea, dry cough, hypoxia, diffuse infiltrates on methotrexate (ACR 2021 Fraenkel)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningbiologic_serious_infection_or_tb_reactivation
    Fever / sepsis / reactivated TB or HBV on a TNFi/biologic/JAKi (ACR 2021 Fraenkel; EULAR 2023 Smolen)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningcervical_myelopathy_atlantoaxial
    Progressive limb weakness, gait change, Lhermitte sign, or atlanto-axial instability — pre-intubation airway risk (EULAR 2023 Smolen)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverehigh_disease_activity_failing_target
    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)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverejaki_in_high_cv_or_cancer_risk
    JAKi considered in age >65 / established CV disease / current-or-former smoker / malignancy history (ORAL Surveillance Ytterberg NEJM 2022)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepregnancy_on_teratogenic_dmard
    Pregnancy or conception planned while on methotrexate or leflunomide (EULAR 2023 Smolen; ACR 2020 reproductive)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

RISK_STRATIFICATIONrequiredDrives severity classification
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Recommended regimen

RA treat-to-target DMARD ladder (csDMARD anchor → bDMARD/tsDMARD by target → triple-therapy alt → taper in remission)
axis: ra_treat_to_target_ladderstep 1 - Step 1 — csDMARD anchor at diagnosis (methotrexate) ± short bridging glucocorticoid
Selected step "Step 1 — csDMARD anchor at diagnosis (methotrexate) ± short bridging glucocorticoid" — New RA diagnosis (2010 ACR/EULAR ≥6) — start csDMARD ASAP regardless of activity (EULAR 2023 Smolen window-of-opportunity)
  • methotrexate
    first line
    csDMARD_antimetabolite
    15 mg PO/SC weekly, titrate to 20–25 mg/wk over 4–6 wk • PO/SC • once weekly (max: max 25 mg/week)
    triggers: new_RA_diagnosis, no_pregnancy, no_severe_hepatic_or_renal_impairment
    ACR 2021 Fraenkel / EULAR 2023 Smolen — MTX is the anchor csDMARD; switch PO→SC if GI intolerance or inadequate response before declaring failure
    rxcui 6851
  • folic acid
    add on
    supplement_folate
    5 mg PO weekly (≥24 h after MTX) or 1 mg daily • PO • weekly or daily
    triggers: on_methotrexate
    Mandatory with MTX to reduce stomatitis, GI and hepatic toxicity (ACR 2021 Fraenkel)
  • prednisone
    add on
    glucocorticoid_bridging
    ≤7.5–10 mg/day PO (lowest effective), rapid taper off within ≤3 months • PO • once daily (max: bridging only — not chronic)
    triggers: active_disease_awaiting_csDMARD_onset
    EULAR 2023 Smolen — short-term low-dose bridge while csDMARD takes effect; lowest dose, shortest duration, tapered — chronic glucocorticoids to be avoided
    rxcui 8640
  • sulfasalazine
    contraindication substitute
    csDMARD
    500 mg PO BID, titrate to 1 g BID • PO • BID
    triggers: methotrexate_contraindicated, pregnancy_or_conception_planned
    ACR 2021 Fraenkel — csDMARD alternative when MTX contraindicated; pregnancy-compatible
    rxcui 9524
  • hydroxychloroquine
    add on
    csDMARD_antimalarial
    ≤5 mg/kg/day PO (typically 200–400 mg/day) • PO • once daily
    triggers: mild_disease, triple_therapy_component, pregnancy_compatible_regimen
    ACR 2021 Fraenkel — mild disease / triple-therapy component; pregnancy-compatible; baseline + annual retinal screen
    rxcui 5521

outpatient playbook — drug actions (6)

  1. 1. methotrexate + folic acid
    MTX 15 mg PO/SC weekly → titrate 20–25 mg/wk; folic acid 5 mg weekly • PO/SC • weekly
    trigger: New RA diagnosis, no pregnancy, adequate renal/hepatic function
    Anchor csDMARD started ASAP at diagnosis (ACR 2021 Fraenkel; EULAR 2023 Smolen)
  2. 2. bridging prednisone
    ≤7.5–10 mg PO daily, taper off ≤3 months • PO • daily (bridge only)
    trigger: Active disease awaiting csDMARD onset
    Short-term low-dose bridge — not chronic (EULAR 2023 Smolen)
  3. 3. add/switch bDMARD or tsDMARD
    TNFi (adalimumab 40 mg SC q2wk) / IL-6R (tocilizumab) / abatacept / rituximab / JAKi (tofacitinib 5 mg BID) • SC/IV/PO • agent-specific
    trigger: Target not improving by 3 mo / not met by 6 mo, or poor-prognosis markers
    Target-driven escalation; JAKi with boxed-warning risk weighting (ACR 2021 Fraenkel; ORAL Surveillance Ytterberg NEJM 2022)
  4. 4. triple therapy alternative
    MTX + sulfasalazine 1 g BID + hydroxychloroquine ≤5 mg/kg/d • PO • daily/BID
    trigger: bDMARD/tsDMARD inaccessible or declined
    Cost-effective alternative non-inferior in RACAT (ACR 2021 Fraenkel)
  5. 5. pregnancy-compatible regimen
    HCQ ± sulfasalazine ± low-dose prednisone ± certolizumab; STOP MTX/LEF (LEF cholestyramine washout) • PO/SC • agent-specific
    trigger: Pregnancy or conception planned
    MTX/LEF teratogenic — switch to compatible agents (EULAR 2023 Smolen; ACR 2020 reproductive)
  6. 6. taper in sustained remission
    Eliminate glucocorticoid first → gradual DMARD dose reduction (do not stop MTX abruptly) • PO/SC • taper
    trigger: Sustained remission ≥6 months
    Conditional taper in deep remission — shared decision (ACR 2021 Fraenkel; EULAR 2023 Smolen)

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Symmetric small-joint polyarthritis (MCP/PIP/wrist) + morning stiffness >30–60 min (2010 ACR/EULAR Aletaha); Positive RF and/or anti-CCP/ACPA with joint symptoms (2010 ACR/EULAR Aletaha); Elevated ESR/CRP with inflammatory arthralgia pattern (EULAR 2023 Smolen).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Rheumatoid arthritis** (rheum.rheumatoid-arthritis.core.v1).
Phenotype framing: Psoriatic arthritis / spondyloarthritis, gout/CPPD, SLE, polymyalgia rheumatica, viral (parvovirus B19, hepatitis C, chikungunya) arthritis, sarcoid, paraneoplastic, osteoarthritis; seropositive vs seronegative RA phenotyping (EULAR 2023 Smolen; Aletaha 2010)
Scope: Adult chronic autoimmune symmetric inflammatory polyarthritis; scope = early + established RA, seropositive vs seronegative, treat-to-target with composite disease activity (ACR 2021 Fraenkel; EULAR 2023 Smolen)

No severity triggers fired against current inputs.

Plan

Regimen axis: **RA treat-to-target DMARD ladder (csDMARD anchor → bDMARD/tsDMARD by target → triple-therapy alt → taper in remission)** — step "Step 1 — csDMARD anchor at diagnosis (methotrexate) ± short bridging glucocorticoid".
1. methotrexate 15 mg PO/SC weekly, titrate to 20–25 mg/wk over 4–6 wk PO/SC once weekly (csDMARD_antimetabolite, first line) — ACR 2021 Fraenkel / EULAR 2023 Smolen — MTX is the anchor csDMARD; switch PO→SC if GI intolerance or inadequate response before declaring failure
2. folic acid 5 mg PO weekly (≥24 h after MTX) or 1 mg daily PO weekly or daily (supplement_folate, add on) — Mandatory with MTX to reduce stomatitis, GI and hepatic toxicity (ACR 2021 Fraenkel)
3. prednisone ≤7.5–10 mg/day PO (lowest effective), rapid taper off within ≤3 months PO once daily (glucocorticoid_bridging, add on) — EULAR 2023 Smolen — short-term low-dose bridge while csDMARD takes effect; lowest dose, shortest duration, tapered — chronic glucocorticoids to be avoided
4. sulfasalazine 500 mg PO BID, titrate to 1 g BID PO BID (csDMARD, contraindication substitute) — ACR 2021 Fraenkel — csDMARD alternative when MTX contraindicated; pregnancy-compatible
5. hydroxychloroquine ≤5 mg/kg/day PO (typically 200–400 mg/day) PO once daily (csDMARD_antimalarial, add on) — ACR 2021 Fraenkel — mild disease / triple-therapy component; pregnancy-compatible; baseline + annual retinal screen

Setting playbook (outpatient) — Diagnose early, start csDMARD anchor ASAP, treat-to-target (remission preferred, low disease activity acceptable), screen + vaccinate before immunosuppression, modify CV risk aggressively (ACR 2021 Fraenkel; EULAR 2023 Smolen)
6. methotrexate + folic acid MTX 15 mg PO/SC weekly → titrate 20–25 mg/wk; folic acid 5 mg weekly PO/SC weekly — New RA diagnosis, no pregnancy, adequate renal/hepatic function (Anchor csDMARD started ASAP at diagnosis (ACR 2021 Fraenkel; EULAR 2023 Smolen))
7. bridging prednisone ≤7.5–10 mg PO daily, taper off ≤3 months PO daily (bridge only) — Active disease awaiting csDMARD onset (Short-term low-dose bridge — not chronic (EULAR 2023 Smolen))
8. add/switch bDMARD or tsDMARD TNFi (adalimumab 40 mg SC q2wk) / IL-6R (tocilizumab) / abatacept / rituximab / JAKi (tofacitinib 5 mg BID) SC/IV/PO agent-specific — Target not improving by 3 mo / not met by 6 mo, or poor-prognosis markers (Target-driven escalation; JAKi with boxed-warning risk weighting (ACR 2021 Fraenkel; ORAL Surveillance Ytterberg NEJM 2022))
9. triple therapy alternative MTX + sulfasalazine 1 g BID + hydroxychloroquine ≤5 mg/kg/d PO daily/BID — bDMARD/tsDMARD inaccessible or declined (Cost-effective alternative non-inferior in RACAT (ACR 2021 Fraenkel))
10. pregnancy-compatible regimen HCQ ± sulfasalazine ± low-dose prednisone ± certolizumab; STOP MTX/LEF (LEF cholestyramine washout) PO/SC agent-specific — Pregnancy or conception planned (MTX/LEF teratogenic — switch to compatible agents (EULAR 2023 Smolen; ACR 2020 reproductive))
11. taper in sustained remission Eliminate glucocorticoid first → gradual DMARD dose reduction (do not stop MTX abruptly) PO/SC taper — Sustained remission ≥6 months (Conditional taper in deep remission — shared decision (ACR 2021 Fraenkel; EULAR 2023 Smolen))

Non-pharmacologic actions:
- Latent TB + hepatitis B/C screening before any biologic/JAKi (ACR 2021 Fraenkel)
- Vaccinate before immunosuppression; non-live vaccines on therapy; live vaccines avoided on biologics/JAKi (EULAR 2023 Smolen)
- Aggressive CV risk modification — statin/BP/glycaemic control, smoking cessation (EULAR 2022 CV risk)
- Physical + occupational therapy; joint protection; bone health (EULAR 2023 Smolen)
- Pre-conception planning + MTX/LEF washout (ACR 2020 reproductive)
- Pre-operative cervical-spine flexion-extension imaging if surgery planned (atlanto-axial instability) (EULAR 2023 Smolen)

AVOID / contraindication checks:
- Methotrexate and leflunomide contraindicated in pregnancy and conception washout required (EULAR 2023 Smolen; ACR 2020 reproductive)
- JAKi boxed MACE VTE malignancy serious infection caution age>65 or CV or cancer or smoking risk (ORAL Surveillance Ytterberg NEJM 2022; ACR 2021 Fraenkel)
- No live vaccines on biologics or JAKi (EULAR 2023 Smolen)
- No biologic or JAKi with active infection or untreated latent TB (ACR 2021 Fraenkel; EULAR 2023 Smolen)
- HBV reactivation screen and prophylaxis before rituximab or immunosuppression (EULAR 2023 Smolen)
- Avoid chronic glucocorticoids bridge only lowest dose shortest duration (EULAR 2023 Smolen)
- Methotrexate hold or reduce if eGFR low or LFT >3xULN or cytopenia (ACR 2021 Fraenkel)

Monitoring

Regimen monitoring:
- DAS28-CRP or CDAI or SDAI q1-3mo until target then q3-6mo (ACR 2021 Fraenkel; EULAR 2023 Smolen)
- CBC LFT creatinine q2-4wk during MTX titration then q8-12wk stable (ACR 2021 Fraenkel)
- lipid panel 4-8wk after IL6R or JAKi initiation then periodic (EULAR 2023 Smolen)
- TB and HBV periodic surveillance on biologic or JAKi (ACR 2021 Fraenkel)
- annual hand foot radiographs in early RA for erosive progression (EULAR 2023 Smolen)
- annual retinal screen on hydroxychloroquine (AAO 2016)
- cardiovascular risk reassessment with EULAR 1.5x multiplier (EULAR 2022 CV risk)

Setting (outpatient) monitoring:
- DAS28-CRP/CDAI/SDAI q1-3 months until target then q3-6 months (ACR 2021 Fraenkel)
- CBC + LFT + creatinine on MTX schedule (q2-4 wk titration → q8-12 wk stable) (ACR 2021 Fraenkel)
- Lipids 4-8 wk after IL-6R/JAKi start then periodic (EULAR 2023 Smolen)
- Annual hand/foot radiographs in early RA (EULAR 2023 Smolen)
- Annual retinal exam on hydroxychloroquine (AAO 2016)

Follow-up plan: 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)
- Close-out criterion: long-term treat-to-target + CV + functional + reproductive plan documented

Monitoring phase: Disease activity (DAS28-CRP/CDAI/SDAI) q1–3 months until target then q3–6 months; CBC + LFT + creatinine on MTX schedule (q2–4 wk during titration → q8–12 wk stable); lipids 4–8 wk after IL-6R/JAKi start; periodic TB/HBV surveillance; radiographic progression annually early; CV risk reassessment (ACR 2021 Fraenkel; EULAR 2023 Smolen)

Disposition

Current setting: outpatient — Diagnose early, start csDMARD anchor ASAP, treat-to-target (remission preferred, low disease activity acceptable), screen + vaccinate before immunosuppression, modify CV risk aggressively (ACR 2021 Fraenkel; EULAR 2023 Smolen)

Disposition criteria:
- Continue rheumatology-led outpatient treat-to-target titration
- Refer/admit if septic joint, MTX pneumonitis, severe cytopenia, systemic vasculitis, or myelopathy

Escalation triggers (move to higher acuity):
- 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)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] 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)

Citations

- 2021 ACR RA Treatment Guideline + 2022/2023 EULAR RA management recommendations; 2010 ACR/EULAR classification [PMID:34101387](https://pubmed.ncbi.nlm.nih.gov/34101387/)
- Cited evidence (PMID 36357155) [PMID:36357155](https://pubmed.ncbi.nlm.nih.gov/36357155/)
- Cited evidence (PMID 20872595) [PMID:20872595](https://pubmed.ncbi.nlm.nih.gov/20872595/)
- Cited evidence (PMID 35081280) [PMID:35081280](https://pubmed.ncbi.nlm.nih.gov/35081280/)
- Cited evidence (PMID 28264816) [PMID:28264816](https://pubmed.ncbi.nlm.nih.gov/28264816/)

Last reconciled with current guidelines: 2026-05-22.
References