Rheumatoid Arthritis

A chronic autoimmune disease characterised by persistent synovitis, systemic inflammation and the presence of autoantibodies. Persistent joint inflammation leads to bony erosions, cartilage and tendon degradation, and irreversible joint deformity — but prognosis has improved substantially over the last two decades with early csDMARD use and the availability of biologics.

Demographics

• Prevalence is about 1%, with women affected roughly twice as often as men.
• The most established genetic risk is HLA-DR4.
• A healthy lifestyle (avoiding smoking, healthy weight, healthy diet) reduces the likelihood of developing RA.

Clinical features

Onset is typically insidious, occasionally acute, with symmetrical arthritis affecting the wrists, MCPJs, MTPJs and IPJs. Features suggesting RA:

• Family history of inflammatory arthritis
• Early morning stiffness lasting more than 1 hour
• Swelling in five or more joints, symmetrically distributed
• Bilateral compression tenderness of the metatarsophalangeal joints
• RF and/or anti-CCP antibody positivity
• Symptoms present for more than 6 weeks
• Bony erosions on hand/wrist/foot X-rays (uncommon in early disease)
• Raised CRP/ESR without infection
• Rheumatoid nodules

Investigations

ESR, CRP, RF, anti-CCP, plain X-rays; baseline FBC, U&E, LFT; ANA to help exclude SLE; assess cardiovascular risk (RA itself is an independent CV risk factor).

Management

Early referral to a rheumatologist is essential — RA ultimately requires DMARD therapy, and outcomes are better the earlier treatment starts.

Australia’s Clinical Care Standard

The Australian Rheumatology Association released Australia’s first national RA Clinical Care Standard in November 2023 — 12 quality statements built around 7 guiding principles (high-quality, culturally responsive and holistic care; team-based care; effective communication; shared decision-making; self-management). It frames RA care as a systems-level quality target (timely diagnosis, treat-to-target monitoring, comorbidity screening), not just a drug algorithm (registry: ara-ra-clinical-care-standard-2023; verified 2026-07-23).

DMARD therapy

Current pharmacological recommendations for Australian practice are maintained as a living guideline by ANZMUSC, the Australian Rheumatology Association and Cochrane Musculoskeletal at livingguidelines.org — continuously updated as new evidence emerges, rather than a static document. As of January 2026, PBS restrictions on rituximab for RA have been removed (previously reserved for patients who had failed TNF inhibitors and other bDMARDs) (registry: ara-living-guideline-inflammatory-arthritis; verified 2026-07-23).

csDMARDs (traditional):

Drug	Typical dosing
Methotrexate	10mg orally once weekly, increasing to up to 25mg weekly (oral or SC) + folic acid 5–10mg weekly on a different day
Sulfasalazine	500mg twice daily, increasing gradually to 1.5g twice daily
Hydroxychloroquine	200–400mg daily
Leflunomide	10–20mg daily

Biologic/targeted synthetic DMARDs (specialist-initiated): TNF inhibitors (adalimumab, etanercept, infliximab, golimumab, certolizumab pegol), rituximab (now available without prior-bDMARD-failure restriction, see above), abatacept, tocilizumab, and the JAK inhibitors (tofacitinib, upadacitinib, baricitinib).

csDMARD monitoring (BSR 2025 update)

• FIB-4 + elastography is now preferred over routine liver biopsy for methotrexate liver monitoring in adults with risk factors for liver disease.
• Cardiovascular disease and malignancy are not contraindications to csDMARD therapy.
• csDMARDs should not be routinely stopped perioperatively.
• Monitoring is risk-stratified: induction phase is intensive (week 2, then monthly for 3–6 months); maintenance can extend to 6-monthly in low-risk patients (registry: bsr-csdmards-2025; verified 2026-07-23).

JAK inhibitors — class safety warning

Following the ORAL Surveillance post-marketing trial (2021), the TGA (and FDA/EMA) added a class-wide boxed warning to all JAK inhibitors used for inflammatory arthritis — increased risk of major adverse cardiovascular events, malignancy (including lung cancer and lymphoma), venous thromboembolism and death compared with TNF inhibitors, particularly in patients ≥50 years with an additional cardiovascular risk factor. JAK inhibitors are now generally reserved for patients who have failed or cannot tolerate TNF inhibitors and other bDMARDs.

Before starting a JAK inhibitor: baseline FBC, renal and hepatic function, lipid panel, hepatitis B/C, HIV and TB screening, and ensure pneumococcal and Shingrix vaccination are up to date; repeat bloods at 8–12 weeks (registry: tga-jak-inhibitors; verified 2026-07-08 / ajgp-jak-inhibitors-inflammatory-2025; verified 2026-07-23).

Pain management (BSR 2026)

DMARDs (for active disease) and short-term bridging glucocorticoids are the recommended pharmacological approach to RA pain — not analgesics/NSAIDs alone. Routine neuromodulators are not recommended (gabapentinoids may be considered specifically for neuropathic pain). Non-pharmacological measures — exercise/physiotherapy, occupational therapy, sleep support, psychological interventions and weight management — are recommended alongside drug therapy, not as an afterthought (registry: bsr-pain-management-ia-2026; verified 2026-07-23).

General management goals

Controlling pain/mood/fatigue; normalising physical function; enabling social and work participation; preventing joint damage; minimising cardiovascular complications.

• Lifestyle: exercise and smoking cessation are key. A Mediterranean diet is recommended (reduces cardiovascular risk). Fish oil (2.7g omega-3 daily) is recommended.
• Symptomatic pain relief: NSAIDs, paracetamol and COX-2 inhibitors (celecoxib) after cardiovascular risk assessment; opioids only short-term with regular review.
• Bridging corticosteroids while awaiting specialist review: prednisolone 5–15mg daily, tapered with specialist involvement once in remission (can take 6–12 weeks); a single IM dose of methylprednisolone 120mg can give up to 8 weeks’ relief.

Poor prognostic indicators

High RF titre and/or positive anti-CCP; sustained raised inflammatory markers; swelling in more than 20 joints; impaired function early in disease; early bony erosions; smoking.