Arthritis

Management escalation pathway

• Severity of pain is not a criterium for escalating treatment, treatment will rather be defined by the type and amount of joints affected
• Escalate analgesics and use NSAID (if not contraindicated)
• Prednisone (10-20mg) to be started ideally after consultation with rheumatologist
• Withhold ICPI until resolution of symptoms and tapering of corticoids
• Intra-articular injections only if infection was ruled out (usually done by treating rheumatologist and to be considered if only one joint is affected)
• Consider methotrexate/leflunomide/salazopyrine/TNF blocker if steroid refractory or for steroid sparing purposes (experience and not evidence based)

Assessment and Investigations

• Evaluate pain with visual analogue scale
• Always do X-ray (consider arthropathy, pre-existing arthropathy, metastasis or baseline evaluation)
• If possible, try to objectify arthritis (eg by ultrasound or arthrocentesis) and always consider joint aspiration especially when fever or severe inflammation is present (to rule out septic arthritis and crystalarthropathies)
• Complete rheumatological history regarding differential diagnosis
• Clinical examination of all joints

Autoimmune panel:

• ACPA
• RF
• ANA (by indirect imunofluorescence) followed by more specific analysis if positive result (according to local practice)
• ANCA (to be discussed with rheumatologist)
• Joint biopsy can be done in collaboration with certain centres for scientific purposes

Rheumatology department where joint biopsy is done for scientific purposes

• Ghent University Hospital
• Hopital St-Pierre, Brussels
• Hopital St-Luc, UCL, Brussels
• Hopital Universitaire de Liège, ULG
• University Hospital Leuven