Rheumatoid arthritis

Red Flags

Acute hot swollen joint with fever — joint aspiration to exclude septic arthritis^[1]
Latent or active TB starting biologic — IGRA/Mantoux + chest X-ray; treat latent TB before starting; particular vigilance in TB-endemic settings^[1]
Hepatotoxicity on methotrexate (LFTs >3× ULN) — pause methotrexate, investigate other causes; restart at lower dose if recovers^[1]
Pregnancy planning on methotrexate, leflunomide, or JAK inhibitor — switch ≥3 months pre-conception to safer agent (sulfasalazine, hydroxychloroquine, certolizumab)^[1]

First-line treatment

Interventions

Early DMARD initiation within 3 months of symptom onset^[1]
Window of opportunity — earlier treatment improves long-term outcomes; do not delay for full investigations once diagnosis is reasonably likely
Treat-to-target^[1]
Aim remission (DAS28 <2.6) or low disease activity (DAS28 <3.2); reassess every 1–3 months early disease, every 3–6 months once stable; escalate or switch if target not met
Triple therapy if methotrexate monotherapy insufficient^[1]
Methotrexate + hydroxychloroquine + sulfasalazine — affordable and effective; consider before biologic where cost or access limits biologic
Pre-biologic TB screen — mandatory in TB-endemic regions^[1]
IGRA preferred + chest X-ray; treat latent TB ≥1 month before biologic; reassess annually during therapy

First-line drug therapy

Drug	Class	Adult	Paediatric	Notes
Methotrexate^[1]	Conventional synthetic DMARD (anti-folate)	Start 10–15 mg PO/SC weekly with folic acid 5 mg weekly (different day); titrate to 20–25 mg weekly	—	Anchor first-line per IRA; SC route improves bioavailability; LFT and FBC every 4–8 weeks; alcohol restriction; teratogen — contraception
Hydroxychloroquine^[1]	Antimalarial / immunomodulator	200–400 mg PO daily (max 5 mg/kg actual body weight)	—	Mild RA monotherapy or combination component; baseline retinal exam and annual screening from year 5; safe in pregnancy
Sulfasalazine^[1]	5-aminosalicylate	Start 500 mg PO BD, titrate to 1 g BD-TDS	—	First-line alternative or in pregnancy; FBC and LFT monitoring; sulfa allergy warning; component of triple therapy
Leflunomide^[1]	Conventional synthetic DMARD (DHODH inhibitor)	20 mg PO daily (loading 100 mg × 3 days then 20 mg)	—	Alternative to methotrexate; LFT and BP monitoring; long half-life — colestyramine washout for stopping; teratogen
Anti-TNF (etanercept, adalimumab, infliximab)^[1]	TNF-alpha inhibitor (biologic)	Etanercept 50 mg SC weekly; adalimumab 40 mg SC every 2 weeks; infliximab 3 mg/kg IV at 0, 2, 6 weeks then every 8 weeks	—	Add when conventional DMARD inadequate; latent TB and HBV screen; biosimilars widely available improving access
Tocilizumab^[1]	IL-6 receptor inhibitor	162 mg SC weekly	—	Useful in monotherapy where methotrexate not tolerated; lipid increase, neutropenia, GI perforation risk
Rituximab^[1]	Anti-CD20 monoclonal antibody	1 g IV × 2 doses 2 weeks apart, repeat at 6 months	—	Seropositive RA failing TNF; HBV screen and prophylaxis; vaccinate before; long-lasting immunosuppression

Methotrexate^[1]

Conventional synthetic DMARD (anti-folate)

Adult: Start 10–15 mg PO/SC weekly with folic acid 5 mg weekly (different day); titrate to 20–25 mg weekly
Paediatric: —

Anchor first-line per IRA; SC route improves bioavailability; LFT and FBC every 4–8 weeks; alcohol restriction; teratogen — contraception

Hydroxychloroquine^[1]

Antimalarial / immunomodulator

Adult: 200–400 mg PO daily (max 5 mg/kg actual body weight)
Paediatric: —

Mild RA monotherapy or combination component; baseline retinal exam and annual screening from year 5; safe in pregnancy

Sulfasalazine^[1]

5-aminosalicylate

Adult: Start 500 mg PO BD, titrate to 1 g BD-TDS
Paediatric: —

First-line alternative or in pregnancy; FBC and LFT monitoring; sulfa allergy warning; component of triple therapy

Leflunomide^[1]

Conventional synthetic DMARD (DHODH inhibitor)

Adult: 20 mg PO daily (loading 100 mg × 3 days then 20 mg)
Paediatric: —

Alternative to methotrexate; LFT and BP monitoring; long half-life — colestyramine washout for stopping; teratogen

Anti-TNF (etanercept, adalimumab, infliximab)^[1]

TNF-alpha inhibitor (biologic)

Adult: Etanercept 50 mg SC weekly; adalimumab 40 mg SC every 2 weeks; infliximab 3 mg/kg IV at 0, 2, 6 weeks then every 8 weeks
Paediatric: —

Add when conventional DMARD inadequate; latent TB and HBV screen; biosimilars widely available improving access

Tocilizumab^[1]

IL-6 receptor inhibitor

Adult: 162 mg SC weekly
Paediatric: —

Useful in monotherapy where methotrexate not tolerated; lipid increase, neutropenia, GI perforation risk

Rituximab^[1]

Anti-CD20 monoclonal antibody

Adult: 1 g IV × 2 doses 2 weeks apart, repeat at 6 months
Paediatric: —

Seropositive RA failing TNF; HBV screen and prophylaxis; vaccinate before; long-lasting immunosuppression

Safety-net

Take methotrexate exactly as prescribed (weekly, never daily) — daily dosing causes life-threatening toxicity^[1]
Any infection (chest, urinary, dental, skin) — same-day medical review while on biologic; pause therapy and seek antibiotic^[1]
Tell every healthcare worker about your DMARD or biologic — affects infection management and surgery planning^[1]

Referral criteria

All suspected new RA (early arthritis with persistent synovitis ≥6 weeks)Rheumatology within 4–6 weeks^[1]
Failure of two conventional DMARDs at adequate dose and durationRheumatology for biologic consideration with TB clearance^[1]
Extra-articular RA (vasculitis, scleritis, interstitial lung disease)Subspecialty co-management^[1]
Pregnancy planning on RA medicationJoint rheumatology and obstetric pre-conception clinic^[1]

Clinical summary

Treat-to-target methotrexate-anchored DMARD pathway with biologic add-on for adults with rheumatoid arthritis per IRA guidance.

References

1.Indian Rheumatology Association Guidelines for Rheumatoid Arthritis Management (2023) (2023)