(Adapted from the ACR guidelines)

Step One:

• Establish Early Diagnosis
  
• Document Baseline Disease Activity
  
• Estimate Disease Course

The American College of Rheumatology (ACR) recommends early diagnosis and treatment of rheumatoid arthritis (RA) because studies have shown that early use of disease-modifying antirheumatic drugs (DMARDs) can slow or help inhibit joint damage. Disease activity and damage are also assessed at this time.

Step 2: Initiate Therapy

• Patient Education
  
• Start DMARDs
  
• Consider NSAIDs
  
• Consider Local or Low-Dose Systemic Steroids
  
• Physical/Occupational Therapy
  

Key elements of treatment include patient education and the use of one or more DMARDs. The ACR recommends DMARD use within 3 months of diagnosis for all patients who have ongoing joint pain, morning stiffness, or other signs of active rheumatoid arthritis (RA) despite treatment with nonsteroidal anti-inflammatory drugs (NSAIDs). The use of NSAIDs; local (injected directly into joints) or low-dose oral steroids; or physical or occupational therapy also may be considered.

Step 3: Periodically Assess Disease Activity

• Joint Pain and/or Inflammation?
  
• Stiffness?
  
• Fatigue?
  
• Limited Function?
  
• Unstable or misaligned joints?
  
• Loss of motion?
  
• Deformity?
  
• Blood tests?
  
• X-rays?
  
• Questionnaires?
  

The ACR recommends that patients with rheumatoid arthritis (RA) are regularly examined to see how much joint pain they have, how long their morning stiffness lasts, how long their fatigue lasts, and how many tender and swollen joints they have. Doctors also may look for other signs of disease progression by checking for joint motion or deformity as well as other joint problems, doing blood tests, taking X-rays, and asking questions to measure how well treatment is working.

Step 4: Change/Add DMARDs

• Which medicines have already been tried?
  
• What effect have they had?
  
• Combination therapy?
  

According to the ACR, when the highest dosage of one DMARD does not work within 3 months, it should either be replaced by a new DMARD or used in combination with a new DMARD. DMARD selection will depend on which medicines a patient has already tried. Some patients will need to take more than one DMARD to control their RA. For some patients, even a combination of DMARDs will not prevent joint damage that ultimately requires surgery. For other patients, one or more DMARDs will be effective. These patients will still need regular checkups, as shown in Step 3, to assess their disease activity. The ACR also suggests that rheumatologists be consulted when combination therapy is being considered or whenever a primary care provider is unsure about any aspect of RA diagnosis or treatment.

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