1. The key lesson of modern research into rheumatoid arthritis is: be aggressive. Controlling pain with NSAIDs while watching for progression may make sense in osteoarthritis – it makes none in RA. You will see progression and it will be irreversible. Guidelines around the world now stress starting methotrexate as soon as RA is diagnosed.

2. In theory, diagnosing RA should be easy, given the serum rheumatoid factor test. But real new-onset patients may present with transient flare-ups in various joints, accompanied by nebulous flu-like symptoms and fatigue.

3. Family history can be helpful in these encounters. Ask about history of psoriasis, as psoriatic arthritis can look like RA.

4. It’s possible to have RA while testing negative for rheumatoid factor, and it’s possible to test positive for rheumatoid factor without having RA. About 20% of RA sufferers test negative. Among the over-60s, about 15% of non-RA sufferers will test positive. A new autoantibody test, anti-cyclic citrullinated peptide (anti-CCP), is more specific but still not very sensitive.

5. In the absence of positive rheumatoid factor, a good diagnostic rule of thumb is this: pain and swelling in three or more small joints of the hand, with tenderness at the knuckles (metocarpophalangeal joints) or the bases of the toes (metatarsophalangeal joints), plus at least half an hour of joint stiffness in the early morning, usually predicts RA. Morning stiffness is a classic sign. Symmetrical bilateral involvement is another.

6. High count of rheumatoid factor (or anti-CCP) means higher chance of rapid progression. So does high ESR and C-reactive protein.

7. Differential diagnoses include: psoriatic arthritis, ankylosing spondylitis, reactive arthritis (from chlamydia, Strep, etc.), enteropathic arthritis (from Crohn’s disease, etc.), connective tissue diseases (e.g. lupus), and gout. These arthralgias are more likely to affect large joints, and to be unilateral.

8. Disease-modifying anti-rheumatic drugs (DMARDs) like methotrexate can take a few months to start working. “Bridging” is achieved with steroids. Initial high-dose oral prednisolone (30-60 mg), rapidly tapered, is one option. Another is intramuscular methlyprednisolone 120 mg — this should work for about six weeks. Direct steroid injection into particularly troublesome joints is usually safe, if infection has been excluded. But limit it to three times a year.

9. Methotrexate has proven very safe, but you should do monthly blood count and liver function tests. Intramuscular or subcutaneous methotrexate can get around gastrointestinal side effects. There are many options when it fails, including adding another DMARD (e.g. sulfasalazine) or a low-dose oral steroid (prednisolone 5-10 mg). About 10% of patients won’t respond to any DMARD, and are candidates for the pricey anti-TNF agents. But let a rheumatologist worry about these cases.

10. It’s becoming clear that RA is associated with sharply increased risk of early cardiovascular death. So treat those CVD risk factors as aggressively as you would in diabetes.