Rheumatoid arthritis affects about 0.53% of adults worldwide, twice as often in women, peaking between 55 and 75. This review is a practical restatement of how it should be managed, and the numbers in it are worth carrying by any clinician who sees swollen joints before a rheumatologist does.

There are no formal diagnostic criteria, so diagnosis rests on the history, characteristic swelling at the proximal interphalangeal, metacarpophalangeal and wrist joints, and often autoantibodies and a raised C-reactive protein — though 40 to 60% are autoantibody positive at diagnosis, meaning a substantial minority are not, and seronegativity does not exclude the disease. The critical interval is early: diagnosis ideally within six weeks of symptom onset, so that disease-modifying therapy starts before joint destruction.

The targets are explicit. At least 50% improvement in disease activity by three months, remission or low disease activity by six, measured on a validated index. Methotrexate starts at 7.5-10 mg weekly and rises to 20-25 mg weekly within four to eight weeks — the escalation is part of the regimen, not an option. A short course of glucocorticoid may be added and tapered off within three months, or given as a single depot injection. Where methotrexate is contraindicated, sulfasalazine or leflunomide. About 40% reach remission on this; adding a biological DMARD or a JAK inhibitor raises remission or low disease activity to about 80%, with JAK inhibitors reserved for those without high thromboembolic, cardiovascular or malignancy risk.

Refer suspected inflammatory arthritis within weeks, not after a trial of analgesia
Do not exclude rheumatoid arthritis because autoantibodies are negative
Escalate methotrexate to 20-25 mg weekly within four to eight weeks rather than leaving it at the starting dose
Taper and stop glucocorticoids within three months; they are a bridge, not a treatment
Assess against a validated activity index at three and six months, not on symptom impression

Why it matters

The six-week window and the dose escalation schedule are where non-specialist management usually diverges from guideline care.

The statistics, in plain English

The jump from about 40% remission on first-line treatment to about 80% remission or low disease activity with added biologics or JAK inhibitors is not a like-for-like comparison: the second figure combines remission with low disease activity, a less demanding endpoint. Both are drawn from trial populations, which are younger and better adherent than clinic populations, so real-world rates run lower.