On this page
Referral and warning signs
When to refer
Refer ALL suspected RA cases to Rheumatologist/Specialist for diagnosis confirmation, DMARD initiation/management, monitoring.
Red flags
- Rapidly progressive joint destruction
- Signs of systemic vasculitis
- Significant extra-articular involvement
- Serious infection on immunosuppressants
- Suspected Felty's syndrome
Signs and symptoms
- Joint Symptoms: Symmetrical polyarthritis (≥3 joints), commonly small joints of hands (MCP, PIP)/feet (MTP), wrists, elbows, shoulders, knees, ankles. Pain, swelling, warmth, tenderness. Morning stiffness >1 hour. Reduced range of motion. Late deformities (Ulnar deviation, swan neck, boutonniere).
- Systemic Symptoms: Fatigue, malaise, low-grade fever, weight loss.
- Extra-articular Manifestations: Rheumatoid nodules, Vasculitis, Lung disease (pleuritis, ILD), Cardiac disease (pericarditis), Ocular disease (scleritis, Sjogren's), Anaemia, Felty's syndrome.
Risk factors
- Genetic predisposition (HLA-DR4/DR1)
- Female gender
- Age (peak 40-60 years)
- Smoking
- Environmental factors
Diagnosis
Clinical assessment
Suspect with inflammatory symmetric polyarthritis (esp. hands/feet) + prolonged morning stiffness. Assess for deformities/extra-articular features. Differentiate from OA, Gout, Psoriatic, Reactive, SLE, Viral arthritis.
Investigations
- Blood tests: Rheumatoid Factor (RF - positive ~70-80%, not specific), Anti-Cyclic Citrullinated Peptide (Anti-CCP) Antibodies (more specific, early marker), ESR/CRP (elevated).
- Imaging: X-rays (hands/feet) - early (soft tissue swelling, osteopenia), late (joint space narrowing, marginal erosions, subluxations). Ultrasound/MRI (more sensitive early).
- Synovial Fluid Analysis: Inflammatory fluid (high WBC), exclude crystals/infection.
Diagnostic criteria
Diagnosis often based on classification criteria (e.g., 2010 ACR/EULAR) combining joint pattern, serology, inflammatory markers, duration.
Management
Non-pharmacological management
- Patient Education.
- Physiotherapy/Occupational Therapy (exercise, joint protection, assistive devices).
- Rest (flares) vs Exercise.
- Heat/Cold therapy.
- Splinting.
- Weight management.
- Smoking cessation.
- Psychosocial support.
Pharmacological treatment
- Goal: Remission/low activity, prevent damage. Requires specialist.
- Symptomatic Relief: NSAIDs (lowest dose/duration, with PPI), Corticosteroids (low-dose oral bridge, intra-articular for flares).
- Disease-Modifying Anti-Rheumatic Drugs (DMARDs): Start early.
- - csDMARDs: Methotrexate (MTX - anchor drug), Sulfasalazine (SSZ), Leflunomide (LEF), Hydroxychloroquine (HCQ).
- - bDMARDs: (If csDMARDs fail) TNF inhibitors (Etanercept, Adalimumab), Rituximab, Abatacept, Tocilizumab.
- - tsDMARDs: JAK inhibitors (Tofacitinib etc).
- Combination therapy often used.
Monitoring
Monitor disease activity (joint counts, global assessment, ESR/CRP - DAS28). Monitor treatment efficacy & toxicity (regular bloods for DMARDs). Monitor complications/extra-articular features. Periodic X-rays.
Complications
- Joint destruction/disability
- Extra-articular disease
- Increased cardiovascular risk
- Osteoporosis
- Infections
- Lymphoma
- Medication side effects
Prevention
- Smoking cessation.
- Early diagnosis and treatment.
Patient education
- Explain RA nature and goals.
- Importance of early/continuous DMARDs.
- Specific DMARD info (dosing, monitoring, side effects, contraception).
- Role of NSAIDs/steroids vs DMARDs.
- Lifestyle measures.
- Vaccinations.
- Recognizing flares.
- Support resources.
Uganda-specific notes
Diagnosis often delayed. Access to serology, specialists, DMARDs (esp biologics/JAKi), monitoring limited. Management often relies on NSAIDs/steroids, limited csDMARDs.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 10, Section 10.2.1