1. At the OPD visit

• Confirm diagnosis and disease activity: joint examination, ESR/CRP, CBC, liver and kidney function.
• Tests often needed before DMARDs: rheumatoid factor, anti-CCP, hepatitis B/C, TB screening if biologic/JAK therapy may be used, pregnancy test where relevant.
• X-ray or ultrasound of affected hands/feet or other joints, as appropriate.
• Assess comorbidities: infection risk, lung disease, liver disease, renal disease, cardiovascular risk, vaccinations.

2. Medicines

• NSAID such as naproxen or ibuprofen may reduce pain and stiffness, if safe for the patient.
• Use the lowest effective dose and consider stomach protection if indicated.
• Avoid or use great caution with kidney disease, peptic ulcer/bleeding, anticoagulants, uncontrolled hypertension, or heart failure.
• Short course corticosteroid tablets or an injection into a joint may be used as a temporary “bridge” while DMARDs begin working. Long-term steroid use should generally be avoided due to diabetes, osteoporosis, infection, cataract, and other risks.

• Methotrexate is commonly first choice, often with folic acid.
• If unsuitable: sulfasalazine, leflunomide, or hydroxychloroquine may be options.
• If control is inadequate, the specialist may use combinations or advance to:
  • Biologic DMARDs: TNF inhibitors, abatacept, tocilizumab, rituximab, etc.
  • Targeted synthetic DMARDs: JAK inhibitors such as tofacitinib, baricitinib, upadacitinib, depending on eligibility and risk profile.

3. Monitoring

• CBC, liver function, kidney function, ESR/CRP at intervals decided by the clinician, especially after starting or changing DMARDs.
• Review disease activity monthly until controlled, then less often.
• Do not stop methotrexate, leflunomide, biologics, or steroids suddenly without medical advice.
• Avoid live vaccines while significantly immunosuppressed. Keep influenza, pneumococcal, COVID-19, and other routine vaccines up to date.

4. Non-drug OPD advice

• Physiotherapy and occupational therapy.
• Daily gentle range-of-motion and strengthening exercises.
• Regular low-impact activity: walking, cycling, swimming.
• Stop smoking, maintain healthy weight, adequate sleep.
• Joint protection, splints or assistive devices when needed.
• Calcium/vitamin D and bone protection assessment if steroids are used.

Seek urgent medical care now if

• Fever, chills, or feeling severely unwell while on DMARDs/biologics.
• A single joint becomes suddenly very hot, red, swollen, and extremely painful. Septic arthritis must be excluded.
• Shortness of breath, chest pain, coughing blood.
• Pregnancy or possible pregnancy while taking methotrexate or leflunomide.