Rheumatoid arthritis
Encounter flow
12/12 authoredCanonical 12-phase frame with authored status for this dossier.
Frame
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)
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)
- informationallife_threateningseptic_arthritis_on_ra_jointAcutely 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_pneumonitisNew 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_reactivationFever / 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_atlantoaxialProgressive 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_targetDAS28-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_riskJAKi 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_dmardPregnancy 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.
Recommended regimen
RA treat-to-target DMARD ladder (csDMARD anchor → bDMARD/tsDMARD by target → triple-therapy alt → taper in remission)- methotrexatefirst linecsDMARD_antimetabolite15 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_impairmentACR 2021 Fraenkel / EULAR 2023 Smolen — MTX is the anchor csDMARD; switch PO→SC if GI intolerance or inadequate response before declaring failurerxcui 6851
- folic acidadd onsupplement_folate5 mg PO weekly (≥24 h after MTX) or 1 mg daily • PO • weekly or dailytriggers: on_methotrexateMandatory with MTX to reduce stomatitis, GI and hepatic toxicity (ACR 2021 Fraenkel)
- prednisoneadd onglucocorticoid_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_onsetEULAR 2023 Smolen — short-term low-dose bridge while csDMARD takes effect; lowest dose, shortest duration, tapered — chronic glucocorticoids to be avoidedrxcui 8640
- sulfasalazinecontraindication substitutecsDMARD500 mg PO BID, titrate to 1 g BID • PO • BIDtriggers: methotrexate_contraindicated, pregnancy_or_conception_plannedACR 2021 Fraenkel — csDMARD alternative when MTX contraindicated; pregnancy-compatiblerxcui 9524
- hydroxychloroquineadd oncsDMARD_antimalarial≤5 mg/kg/day PO (typically 200–400 mg/day) • PO • once dailytriggers: mild_disease, triple_therapy_component, pregnancy_compatible_regimenACR 2021 Fraenkel — mild disease / triple-therapy component; pregnancy-compatible; baseline + annual retinal screenrxcui 5521
outpatient playbook — drug actions (6)
- 1. methotrexate + folic acidMTX 15 mg PO/SC weekly → titrate 20–25 mg/wk; folic acid 5 mg weekly • PO/SC • weeklytrigger: New RA diagnosis, no pregnancy, adequate renal/hepatic functionAnchor csDMARD started ASAP at diagnosis (ACR 2021 Fraenkel; EULAR 2023 Smolen)
- 2. bridging prednisone≤7.5–10 mg PO daily, taper off ≤3 months • PO • daily (bridge only)trigger: Active disease awaiting csDMARD onsetShort-term low-dose bridge — not chronic (EULAR 2023 Smolen)
- 3. add/switch bDMARD or tsDMARDTNFi (adalimumab 40 mg SC q2wk) / IL-6R (tocilizumab) / abatacept / rituximab / JAKi (tofacitinib 5 mg BID) • SC/IV/PO • agent-specifictrigger: Target not improving by 3 mo / not met by 6 mo, or poor-prognosis markersTarget-driven escalation; JAKi with boxed-warning risk weighting (ACR 2021 Fraenkel; ORAL Surveillance Ytterberg NEJM 2022)
- 4. triple therapy alternativeMTX + sulfasalazine 1 g BID + hydroxychloroquine ≤5 mg/kg/d • PO • daily/BIDtrigger: bDMARD/tsDMARD inaccessible or declinedCost-effective alternative non-inferior in RACAT (ACR 2021 Fraenkel)
- 5. pregnancy-compatible regimenHCQ ± sulfasalazine ± low-dose prednisone ± certolizumab; STOP MTX/LEF (LEF cholestyramine washout) • PO/SC • agent-specifictrigger: Pregnancy or conception plannedMTX/LEF teratogenic — switch to compatible agents (EULAR 2023 Smolen; ACR 2020 reproductive)
- 6. taper in sustained remissionEliminate glucocorticoid first → gradual DMARD dose reduction (do not stop MTX abruptly) • PO/SC • tapertrigger: Sustained remission ≥6 monthsConditional taper in deep remission — shared decision (ACR 2021 Fraenkel; EULAR 2023 Smolen)
Auto-drafted A&P note
outpatientSubjective
- 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.
- 2021 ACR RA Treatment Guideline + 2022/2023 EULAR RA management recommendations; 2010 ACR/EULAR classification — PMID:34101387
- Cited evidence (PMID 36357155) — PMID:36357155
- Cited evidence (PMID 20872595) — PMID:20872595
- Cited evidence (PMID 35081280) — PMID:35081280
- Cited evidence (PMID 28264816) — PMID:28264816