Table 4

 Final set of 12 recommendations on the management of early arthritis based on both evidence and expert opinion

CRP, C reactive protein; DMARD, disease modifying antirheumatic drug; ESR, erythrocyte sedimentation rate; HAQ, Health Assessment Questionnaire; MRI, magnetic resonance imaging.
• Arthritis is characterised by the presence of joint swelling, associated with pain or stiffness. Patients presenting with arthritis of more than one joint should be referred to, and seen by, a rheumatologist, ideally within six weeks after the onset of symptoms.
• Clinical examination is the method of choice for detecting synovitis. In doubtful cases, ultrasound, power Doppler, and MRI might be helpful to detect synovitis.
• Exclusion of diseases other than rheumatoid arthritis requires careful history taking and clinical examination, and ought to include at least the following laboratory tests: complete blood cell count, urinary analysis, transaminases, antinuclear antibodies.
• In every patient presenting with early arthritis to the rheumatologist, the following factors predicting persistent and erosive disease should be measured: number of swollen and tender joints, ESR or CRP, levels of rheumatoid factor and anti-CCP antibodies, and radiographic erosions.
• Patients at risk of developing persistent or erosive arthritis should be started with DMARDs as early as possible, even if they do not yet fulfil established classification criteria for inflammatory rheumatological diseases.
• Patient information concerning the disease and its treatment and outcome is important. Education programmes aimed at coping with pain, disability, and maintenance of work ability may be employed as adjunct interventions.
• NSAIDs have to be considered in symptomatic patients after evaluation of gastrointestinal, renal, and cardiovascular status.
• Systemic glucocorticoids reduce pain and swelling and should be considered as adjunctive treatment (mainly temporary), as part of the DMARD strategy. Intra-articular glucocorticoid injections should be considered for the relief of local symptoms of inflammation.
• Among the DMARDS, methotrexate is considered to be the anchor drug, and should be used first in patients at risk of developing persistent disease.
• The main goal of DMARD treatment is to achieve remission. Regular monitoring of disease activity and adverse events should guide decisions on choice and changes in treatment strategies (DMARDs including biological agents).
• Non-pharmaceutical interventions such as dynamic exercises, occupational therapy, and hydrotherapy can be applied as adjuncts to pharmaceutical interventions in patients with early arthritis.
• Monitoring of disease activity should include tender and swollen joint count, patient’s and physician’s global assessments, ESR, and CRP. Arthritis activity should be assessed at one to three month intervals, for as long as remission is not achieved. Structural damage should be assessed by radiographs of hands and feet every 6 to 12 months during the first few years. Functional assessment (for example, HAQ) can be used to complement the disease activity and structural damage monitoring.