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Arthritis

Last updated 31 May 2026 · Rheumatology

📋 Key Information Summary

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  • Diagnostic strategy: Arthritis presents as monoarticular, oligoarticular (2–4 joints), or polyarticular (≥5 joints); the pattern, acuity, and inflammatory features guide the differential and urgency of investigation.
  • Acute monoarthritis is septic arthritis until proven otherwise — joint aspiration with synovial fluid microscopy, culture, and crystal analysis is mandatory; do not delay aspiration for imaging.
  • Acute rheumatic fever (ARF) remains a significant burden in Aboriginal and Torres Strait Islander communities and requires clinical diagnosis using the revised Jones Criteria (2015) with population-specific thresholds.
  • ARF prophylaxis: Secondary prophylaxis with intramuscular benzathine penicillin G every 28 days is the cornerstone of preventing recurrent rheumatic heart disease.
  • Septic arthritis is a medical emergency — empirical IV flucloxacillin (or vancomycin if MRSA risk) should commence within 1 hour of aspiration; Gram-positive cocci (Staphylococcus aureus) cause ~60% of cases in Australia.
  • Rheumatoid arthritis (RA): Early referral to rheumatology within 6 weeks of symptom onset improves outcomes; the treat-to-target strategy aims for remission or low disease activity using DAS28 scoring.
  • DMARDs are first-line in RA — methotrexate (oral or SC, up to 25 mg weekly) is the anchor drug; add folic acid 5 mg weekly; escalate to biologic DMARDs (TNF inhibitors, IL-6 inhibitors, JAK inhibitors) if inadequate response after 3–6 months.
  • NSAIDs and corticosteroids provide symptom relief but do not modify disease progression in RA; use the lowest effective dose for the shortest duration.
  • Juvenile idiopathic arthritis (JIA) is the most common chronic rheumatic condition in children; early ophthalmological screening for uveitis is essential, particularly in ANA-positive oligoarticular JIA.
  • Elderly-onset arthritis includes polymyalgia rheumatica (PMR), erosive OA, and late-onset RA; corticosteroid use requires vigilance for osteoporosis, diabetes, and infection risk.
  • Crystal arthropathies — gout (monosodium urate) and pseudogout (calcium pyrophosphate) must be excluded by polarised light microscopy in all acute monoarthritis presentations.
  • Aboriginal and Torres Strait Islander populations experience disproportionately higher rates of ARF, rheumatic heart disease, gout, and delayed access to rheumatology services — culturally safe care and remote outreach are essential.
  • Screening investigations for inflammatory arthritis: ESR, CRP, RF, anti-CCP antibodies, ANA, FBC, LFTs, urate; X-rays of affected joints (hands/feet for RA) and ultrasound for early synovitis detection.

Introduction & Australian Epidemiology

Arthritis — inflammation of one or more joints — is one of the most common presentations in Australian general practice and a leading cause of disability. The term encompasses a broad spectrum of disorders ranging from self-limiting viral arthritis to destructive, systemic autoimmune diseases and life-threatening septic arthritis. An evidence-based diagnostic strategy is essential to distinguish inflammatory from non-inflammatory causes and to identify conditions requiring urgent intervention.

In Australia, musculoskeletal conditions affect approximately 7.3 million people, with arthritis accounting for a significant proportion of chronic disease burden. Osteoarthritis (OA) affects over 2.1 million Australians, rheumatoid arthritis (RA) approximately 456,000, gout over 200,000, and juvenile idiopathic arthritis (JIA) around 6,000 children and adolescents. The prevalence of arthritis increases with age, affecting nearly 50% of adults aged ≥65 years.

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Health inequity: Aboriginal and Torres Strait Islander Australians experience acute rheumatic fever (ARF) at rates 50–100 times higher than the non-Indigenous population, with rheumatic heart disease (RHD) remaining a significant cause of cardiovascular morbidity and mortality in remote and regional communities across northern and central Australia.

The Australian healthcare system provides rheumatology services primarily through hospital outpatient departments, with significant wait times in the public sector (often 3–12 months). Timely access to rheumatology expertise — critical for early RA and JIA management — remains a challenge, particularly in rural and remote areas where specialist density is lowest.

Australian Burden of Disease — Key Statistics

Condition Estimated Prevalence (Australia) Peak Demographic Key Australian Consideration
Osteoarthritis ~2.1 million Age ≥55 years Leading cause of joint replacement surgery
Rheumatoid arthritis ~456,000 40–70 years (F > M) Early DMARD access critical; PBS biologics available
Gout ~200,000+ Males ≥40 years Increasing prevalence; strongly associated with CKD
Psoriatic arthritis ~100,000 30–50 years Often underdiagnosed; axial disease may precede skin
Acute rheumatic fever ~500–800 new cases/year 5–14 years (ATSI children) Endemic in NT, Qld, WA; RHD register active
Juvenile idiopathic arthritis ~6,000 1–16 years Paediatric rheumatology workforce shortage

Arthritis Diagnostic Strategy Model

The diagnostic approach to arthritis follows a structured model that integrates the number of affected joints (mono-, oligo-, or polyarticular), the tempo of onset (acute, subacute, or chronic), and the presence or absence of systemic features. This framework prioritises the exclusion of dangerous diagnoses (septic arthritis, crystal arthropathy, vasculitis) before pursuing chronic inflammatory or degenerative aetiologies.

Step 1 — Characterise the Pattern

1
Number of joints
Monoarticular (1 joint), oligoarticular (2–4 joints), or polyarticular (≥5 joints)
2
Tempo of onset
Acute (<2 weeks), subacute (2–12 weeks), or chronic (>12 weeks)
3
Inflammatory vs non-inflammatory
Warmth, swelling, morning stiffness >30 min, systemic symptoms → inflammatory
4
Extra-articular features
Rash, uveitis, oral ulcers, enthesitis, urethritis, fever → systemic disease

Step 2 — Differential Diagnosis by Pattern

Pattern Acute (<2 weeks) Subacute / Chronic (>2 weeks)
Monoarticular Septic arthritis, crystal arthropathy (gout, pseudogout), trauma, reactive arthritis TB arthritis, pigmented villonodular synovitis, osteoarthritis, osteonecrosis
Oligoarticular Reactive arthritis, gonococcal arthritis, ARF, psoriatic arthritis Psoriatic arthritis, spondyloarthropathy, early RA, Lyme disease
Polyarticular Viral arthritis (parvovirus B19, chikungunya), ARF, flare of known RA Rheumatoid arthritis, SLE, Sjögren syndrome, systemic vasculitis, PMR

Step 3 — Investigations

All patients with suspected inflammatory arthritis require baseline blood work. The urgency and scope of investigations depends on the clinical pattern.

ESSENTIAL FBC, ESR, CRP, UEC, LFTs Baseline inflammatory markers and organ function; available same-day in most Australian laboratories
ESSENTIAL Joint aspiration with synovial fluid analysis Mandatory for any acute monoarthritis — microscopy (WBC count, crystals under polarised light), Gram stain, culture, crystal analysis. MBS item 13710 (arthrocentesis)
AVAILABLE Rheumatoid factor (RF) and anti-CCP antibodies Anti-CCP has ~95% specificity for RA; both available through major pathology providers (Sonic, Healius, Pathology Queensland)
AVAILABLE Antinuclear antibody (ANA) Screening test for SLE and JIA uveitis risk; report with titre and pattern
AVAILABLE Serum urate May be normal during acute gout attack; best measured ≥2 weeks after flare resolution. MBS item 66551
AVAILABLE X-rays of affected joints (hands, feet for RA) Baseline films for erosions, joint space narrowing; MBS item 58500 (single region). Ultrasound for early synovitis if available
REFERRAL MRI (affected joints) Early erosive disease, sacroiliitis (axial spondyloarthropathy); usually arranged by rheumatology
AVAILABLE Blood cultures If systemic infection/sepsis suspected alongside septic arthritis
AVAILABLE ASO titre / anti-DNase B Supportive (not diagnostic) for ARF; paired sera 10–14 days apart

Step 4 — When to Refer

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Emergency referral (same day): Suspected septic arthritis — aspirate, start empirical antibiotics, and arrange urgent orthopaedic review for possible arthroscopic washout. Neonatal septic hip is a surgical emergency.

Urgent rheumatology referral (within 2–4 weeks) is indicated for:

  • Suspected RA with ≥1 swollen joint persisting >6 weeks
  • Suspected inflammatory arthritis (any type) not responding to initial management
  • Suspected connective tissue disease (SLE, scleroderma, myositis)
  • Paediatric arthritis or suspected JIA
  • New-onset PMR with atypical features (age <60, systemic symptoms, asymmetry)

Rheumatic Fever & Septic Arthritis

Acute Rheumatic Fever (ARF)

Acute rheumatic fever is a delayed, non-suppurative inflammatory sequel of Group A Streptococcus (GAS) pharyngitis. It remains endemic in Aboriginal and Torres Strait Islander communities across northern and central Australia and is a major contributor to rheumatic heart disease (RHD). Diagnosis is clinical, using the revised 2015 Jones Criteria, which incorporate different thresholds for high-risk populations.

Revised Jones Criteria (2015) — Diagnosis of ARF

First episode of ARF requires 2 major OR 1 major + 2 minor criteria, plus evidence of preceding GAS infection. In high-risk populations (including Aboriginal and Torres Strait Islander Australians), the threshold is lowered.

Criterion Low-Risk Populations High-Risk Populations (incl. ATSI)
Major Carditis (clinical/subclinical), polyarthritis, chorea, erythema marginatum, subcutaneous nodules Same major criteria PLUS monoarthritis accepted as a major criterion
Minor Fever (≥38.5°C), ESR ≥30 mm/hr or CRP ≥30 mg/L, prolonged PR interval (age-adjusted) Same minor criteria PLUS fever ≥38°C, ESR ≥30 or CRP ≥30, polyarthralgia (as minor)
Evidence of GAS Positive throat swab, elevated ASO titre, or elevated anti-DNase B Same
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Key change in 2015 criteria: For high-risk populations (including ATSI), monoarthralgia is no longer accepted as a minor criterion — but monoarthritis is now a major criterion. This lowers the diagnostic threshold in communities where ARF is endemic.

Management of ARF

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Benzathine Penicillin G (BPG)
Bicillin L-A® · Long-acting penicillin
Adult dose 1.2 million units IM STAT (treatment of GAS pharyngitis)
Paediatric dose 600,000 units IM STAT (<20 kg); 1.2 million units IM STAT (≥20 kg)
Route Intramuscular
Duration Single dose for GAS eradication; secondary prophylaxis every 28 days for 10+ years (or until age 21 — longer if RHD documented)
Renal adjustment None required
PBS status ✔ PBS General Benefit
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Aspirin (for arthritis of ARF)
Aspirin · Salicylate / anti-inflammatory
Adult dose 60–100 mg/kg/day PO in 4–5 divided doses (max 8 g/day); target serum salicylate 1.2–2.4 mmol/L
Paediatric dose 80–100 mg/kg/day PO in divided doses; reduce after 48 hrs of fever resolution
Note Dramatic response to high-dose aspirin is characteristic of ARF arthritis; if no improvement within 48 hrs, reconsider diagnosis
PBS status ✔ PBS General Benefit
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Prednisolone (for carditis)
Prednisolone · Solone® · Corticosteroid
Adult dose 1–2 mg/kg/day PO (max 80 mg) for severe carditis with heart failure; taper over 2–3 weeks
Paediatric dose 1–2 mg/kg/day PO for severe carditis; taper over 2–3 weeks
Note Indicated for moderate-severe carditis with cardiomegaly or heart failure; mild carditis managed with aspirin alone
PBS status ✔ PBS General Benefit

Septic Arthritis

Septic arthritis is an orthopaedic and infectious disease emergency. Delayed treatment (>7 days) results in irreversible joint destruction in the majority of cases. The most common pathogen is Staphylococcus aureus (~60% of cases), followed by Neisseria gonorrhoeae in sexually active young adults. In Australia, CA-MRSA is an increasingly important consideration, particularly in remote communities.

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Clinical urgency: Any acute hot, swollen joint must be aspirated within 1 hour of presentation. Commence empirical IV antibiotics immediately after aspiration — do not wait for culture results. Joint destruction begins within days of untreated infection.

Clinical Features of Septic Arthritis

  • Acute onset (hours to days) of a single hot, swollen, exquisitely painful joint
  • Reduced range of motion — often unable to bear weight
  • Systemic features: fever (>38.5°C), rigors, malaise (may be absent in elderly/immunosuppressed)
  • Common sites: knee (50%), hip (20%), shoulder, ankle, wrist
  • Risk factors: joint prosthesis, RA, diabetes, IV drug use, immunosuppression, recent joint procedure

Synovial Fluid Analysis

Parameter Normal Non-inflammatory (OA) Inflammatory (RA, crystal) Septic
WBC (×10⁹/L) <0.2 0.2–2.0 2.0–50 >50 (often >100)
% Neutrophils <25% <25% ≥50% ≥75% (often >90%)
Appearance Clear, straw-coloured Clear to slightly turbid Turbid Purulent, turbid
Gram stain Negative Negative Negative Positive in 50–75%
Crystals None None MSU or CPPD (polarised light) May coexist with infection
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Crystal disease and sepsis can coexist: The presence of monosodium urate (gout) or calcium pyrophosphate (pseudogout) crystals does NOT exclude concurrent septic arthritis. If synovial fluid WBC is markedly elevated or clinical suspicion remains high, treat empirically for infection.

Empirical Antibiotic Therapy for Septic Arthritis

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Flucloxacillin
Staphlex® · Penicillinase-resistant penicillin
Adult dose 2 g IV every 6 hours
Paediatric dose 50 mg/kg IV every 6 hours (max 2 g per dose)
Route IV initially; switch to oral when clinically improving (usually 2–5 days IV)
Duration 4–6 weeks total (IV then oral); 6 weeks if prosthetic joint infection
Renal adjustment No dose adjustment; consider risk of interstitial nephritis
PBS status ✔ PBS General Benefit
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Vancomycin
Vancocin® · Glycopeptide antibiotic
Indication MRSA risk (known colonisation, CA-MRSA prevalent area, prosthetic joint, penicillin allergy)
Adult dose 15–20 mg/kg IV every 8–12 hours; target trough 15–20 mg/L
Renal adjustment Dose and interval adjustment based on renal function and trough levels
PBS status ✔ PBS General Benefit (hospital authority)
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Ceftriaxone
Rocephin® · Third-generation cephalosporin
Indication Suspected gonococcal arthritis (sexually active young adult, migratory arthralgia, urethritis/cervicitis)
Adult dose 1 g IV or IM once daily
Paediatric dose 50 mg/kg IV/IM once daily (max 1 g)
Duration 7–14 days (may switch to oral cefixime or ciprofloxacin once sensitivities confirmed)
PBS status ✔ PBS General Benefit

Surgical Management

In addition to antibiotics, surgical drainage (arthroscopic or open) is required for most cases of septic arthritis, particularly for large joints (knee, hip, shoulder) and prosthetic joint infections. Repeated needle aspiration may be adequate for small joints in responsive patients. Orthopaedic referral should occur within 24 hours of diagnosis.

Rheumatoid Arthritis — Principles of Management

Rheumatoid arthritis (RA) is a chronic, systemic, autoimmune inflammatory arthritis characterised by symmetric polyarthritis, progressive joint destruction, and significant extra-articular manifestations. The goal of modern management is early diagnosis and initiation of disease-modifying therapy within the "window of opportunity" — ideally within 3–6 months of symptom onset — using a treat-to-target strategy.

Diagnostic Criteria

The 2010 ACR/EULAR classification criteria (score ≥6/10) are used for early RA identification:

  • Joint involvement: 1 large joint (0) → 2–10 large joints (1) → 1–3 small joints (2) → 4–10 small joints (3) → >10 joints (at least 1 small) (5)
  • Serology: RF− and anti-CCP− (0) → low-positive RF or anti-CCP (2) → high-positive RF or anti-CCP (3)
  • Acute-phase reactants: Normal CRP and ESR (0) → abnormal CRP or ESR (1)
  • Duration: <6 weeks (0) → ≥6 weeks (1)

Treat-to-Target Strategy

1
Target: Remission or low disease activity
DAS28 <2.6 (remission) or <3.2 (low disease activity); assess every 1–3 months until target achieved
2
Conventional DMARD first
Methotrexate monotherapy as anchor drug; add hydroxychloroquine, sulfasalazine, or leflunomide if needed
3
Escalate if target not met at 3–6 months
Combination csDMARDs or add biologic DMARD (TNF inhibitor, IL-6R inhibitor, T-cell co-stimulation blocker, or JAK inhibitor)
4
Maintain and taper
If sustained remission (≥6 months), cautiously reduce corticosteroids then DMARDs; never stop DMARDs abruptly

Disease-Modifying Anti-Rheumatic Drugs (DMARDs)

Conventional Synthetic DMARDs (csDMARDs)

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Methotrexate
Methoblastin® · Folate antagonist / anchor DMARD
Adult dose Start 7.5–10 mg PO/SC once weekly; titrate to 20–25 mg once weekly over 4–8 weeks
Paediatric dose 10–15 mg/m² PO/SC once weekly (JIA)
Essential adjunct Folic acid 5 mg weekly (take on a different day to methotrexate); reduces GI and mucosal side effects
Renal adjustment Reduce dose if eGFR <30 mL/min; avoid if eGFR <15 mL/min
Monitoring FBC, LFTs, UEC every 2 weeks initially, then monthly once stable; chest X-ray at baseline
Contraindication Pregnancy, breastfeeding, significant hepatic disease, significant lung disease
PBS status ✔ PBS General Benefit
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Hydroxychloroquine
Plaquenil® · Antimalarial / immunomodulator
Adult dose 200–400 mg PO daily (≤5 mg/kg/day actual body weight)
Key monitoring Baseline and annual ophthalmological review after 5 years (retinal toxicity screening)
PBS status ✔ PBS General Benefit
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Sulfasalazine
Salazopyrin EN® · Sulfonamide / DMARD
Adult dose Start 500 mg PO daily; increase by 500 mg weekly to 1–3 g/day in divided doses
Monitoring FBC, LFTs fortnightly for first 3 months then monthly; watch for leucopenia, hepatotoxicity
PBS status ✔ PBS General Benefit
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Leflunomide
Arava® · Pyrimidine synthesis inhibitor
Adult dose Loading dose 100 mg PO daily for 3 days (often omitted due to GI effects); maintenance 10–20 mg PO daily
Contraindication Pregnancy (teratogenic — active metabolite has long half-life; cholestyramine washout required)
PBS status ⚠ PBS Authority Required

Biologic DMARDs (bDMARDs) — PBS Authority Required

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PBS criteria for bDMARDs: Authority Required. Patient must have severe active RA (DAS28 >5.1) that has failed adequate trial of at least 2 csDMARDs (including methotrexate ≥15 mg/week for ≥3 months) unless intolerant/contraindicated. Treatment must be initiated and supervised by a rheumatologist.
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Adalimumab
Humira® · TNF-α inhibitor
Adult dose 40 mg SC every 2 weeks
Key precautions Screen for TB (QuantiFERON) and hepatitis B before initiation; live vaccines contraindicated
PBS status 🔴 PBS Authority Required (Specialist)
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Etanercept
Enbrel® · TNF receptor fusion protein
Adult dose 50 mg SC once weekly (or 25 mg twice weekly)
PBS status 🔴 PBS Authority Required (Specialist)
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Tocilizumab
Actemra® · IL-6 receptor inhibitor
Adult dose 8 mg/kg IV every 4 weeks OR 162 mg SC weekly
Key monitoring FBC (risk of neutropenia), LFTs, lipids; may mask infection signs (suppresses CRP and fever)
PBS status 🔴 PBS Authority Required (Specialist)
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Tofacitinib
Xeljanz® · JAK inhibitor (tsDMARD)
Adult dose 5 mg PO twice daily (or 11 mg XR once daily)
Key precaution Avoid in patients aged ≥50 with ≥1 cardiovascular risk factor (ORAL Surveillance study); VTE risk; herpes zoster risk
PBS status 🔴 PBS Authority Required (Specialist)

Symptomatic and Bridging Therapy

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Naproxen
Naprosyn® · NSAID
Adult dose 250–500 mg PO BD with food
Note Symptomatic relief only — does not modify disease; use lowest dose, shortest duration; co-prescribe PPI if GI risk
PBS status ✔ PBS General Benefit
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Prednisolone
Solone® · Corticosteroid (bridging therapy)
Adult dose 5–10 mg PO daily as bridging therapy until DMARDs take effect; taper as soon as possible
Intra-articular Triamcinolone 20–40 mg for individual active joints (by rheumatology or experienced GP)
Key monitoring Bone density (DEXA if >3 months use), blood glucose, BP, ophthalmology if prolonged use
PBS status ✔ PBS General Benefit

Monitoring and Shared Care

RA management requires shared care between rheumatology and general practice. Monitoring parameters depend on the medications in use:

  • Disease activity: DAS28 score every 1–3 months until target achieved, then every 3–6 months
  • Methotrexate: FBC, LFTs, UEC every 2 weeks initially, then every 4–8 weeks once stable
  • Biologic DMARDs: FBC, LFTs, CRP every 3 months; TB screening annually in at-risk populations
  • Cardiovascular risk: RA increases CV risk by 1.5–2×; annual CV risk assessment (absolute CV risk calculator) and aggressive risk factor management
  • Osteoporosis: DEXA at baseline for patients on or likely to require corticosteroids; calcium and vitamin D supplementation
  • Vaccination: Influenza and pneumococcal vaccines recommended (ideally before starting bDMARDs); avoid live vaccines on bDMARDs

Juvenile Idiopathic Arthritis & Arthritis in the Elderly

Juvenile Idiopathic Arthritis (JIA)

JIA is the most common chronic rheumatic disease of childhood, defined as arthritis of unknown cause persisting for ≥6 weeks with onset before age 16. It encompasses several subtypes with distinct clinical features, treatment approaches, and prognoses. Early diagnosis and treatment are essential to prevent irreversible joint damage and growth disturbance.

JIA Subtypes

Subtype % of JIA Key Features Uveitis Risk Prognosis
Oligoarticular (persistent) ~50% ≤4 joints in first 6 months; knees, ankles; ANA+ common; peak 1–5 yrs HIGH (up to 30%) Generally good; risk of uveitis
Oligoarticular (extended) ~20% Starts as oligo, extends to ≥5 joints after 6 months HIGH Moderate; may need systemic DMARDs
Polyarticular (RF+) ~5% Resembles adult RA; symmetric; older girls; RF+, anti-CCP+ Low More erosive; aggressive treatment needed
Polyarticular (RF−) ~15% ≥5 joints; any age; symmetric or asymmetric Moderate Variable
Systemic JIA ~10% Quotidian fever (≥39°C), salmon-pink evanescent rash, serositis, hepatosplenomegaly, lymphadenopathy Very low Risk of macrophage activation syndrome (MAS); requires urgent treatment
Enthesitis-related arthritis ~10% Enthesitis + arthritis; HLA-B27+ common; older boys; sacroiliitis, dactylitis Low (acute anterior uveitis if HLA-B27+) May evolve into adult spondyloarthropathy
Psoriatic JIA ~5% Arthritis + psoriasis, or arthritis + ≥2 of dactylitis, nail pitting, psoriasis in first-degree relative Moderate Variable
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Uveitis screening is critical: Up to 30% of children with ANA-positive oligoarticular JIA develop chronic anterior uveitis, which is often asymptomatic. Slit-lamp examination should be performed every 3 months for high-risk, every 6 months for moderate-risk, and every 12 months for low-risk subtypes (according to AAO/ACR screening guidelines). Delayed detection leads to cataracts, glaucoma, and vision loss.

JIA Treatment — Pyramid

1
NSAIDs + intra-articular corticosteroids
First-line for mild oligoarticular JIA; intra-articular triamcinolone hexacetonide preferred (longer duration)
2
Methotrexate
For polyarticular, extended oligoarticular, or insufficient response to NSAIDs; 10–15 mg/m² SC/PO weekly (max 25 mg); add folic acid
3
Biologic DMARDs
TNF inhibitors (adalimumab, etanercept) for refractory disease; anakinra or canakinumab for systemic JIA; tocilizumab for polyarticular/systemic JIA
4
Systemic corticosteroids
Short courses for systemic JIA with significant systemic features; long-term use avoided due to growth effects

Macrophage Activation Syndrome (MAS)

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Medical emergency in systemic JIA: MAS is a life-threatening complication resembling haemophagocytic lymphohistiocytosis (HLH). Features include sustained fever refractory to treatment, hepatosplenomegaly, cytopenias, hyperferritinaemia (>500 ng/mL — often >10,000), hypertriglyceridaemia, falling ESR with rising ferritin ("ferritin-ESR dissociation"), coagulopathy, and liver dysfunction. Treat with high-dose corticosteroids, anakinra (IL-1 inhibition), and consider ciclosporin in refractory cases. Transfer to paediatric intensive care.

Arthritis in the Elderly

Arthritis in older adults (≥65 years) presents unique diagnostic and management challenges. Degenerative osteoarthritis (OA) is the most common cause, but inflammatory arthritis — including elderly-onset RA (EORA), polymyalgia rheumatica (PMR), crystal arthropathies, and remitting seronegative symmetric synovitis with pitting oedema (RS3PE) — must be actively considered and distinguished.

Polymyalgia Rheumatica (PMR)

PMR is one of the most common inflammatory rheumatic conditions in the elderly, with peak incidence in those aged 70–80 years. It classically presents with bilateral shoulder and hip girdle pain and stiffness (duration >45 minutes in the morning), elevated ESR (typically >40 mm/hr), and a dramatic response to low-dose corticosteroids.

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Prednisolone (PMR)
Solone® · Corticosteroid
Initial dose 12.5–25 mg PO daily (ACR/EULAR 2015 recommendation: 12.5 mg as starting dose)
Expected response Dramatic improvement within 72 hours — if no response, reconsider diagnosis (consider EORA, malignancy, infection)
Taper Reduce by 2.5 mg every 2–4 weeks to 10 mg/day; then by 1 mg every 4–8 weeks. Total treatment duration 1–2 years (minimum)
Essential adjuncts Calcium + vitamin D supplementation; bone protection (bisphosphonate) if osteoporosis risk; PPI if GI risk
PBS status ✔ PBS General Benefit
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Giant cell arteritis (GCA) must be excluded: Up to 15–20% of PMR patients develop GCA. Warn patients to report new headache, jaw claudication, visual symptoms (amaurosis fugax, diplopia), or scalp tenderness. Urgent temporal artery biopsy and/or temporal artery ultrasound should be arranged; commence high-dose prednisolone (40–60 mg/day) immediately if GCA is suspected — do not wait for biopsy.

Elderly-Onset RA (EORA)

RA with onset after age 60 accounts for 10–30% of RA. EORA differs from young-onset RA in several ways:

  • More acute onset, often with prominent systemic features (fever, weight loss, fatigue)
  • Greater frequency of large joint involvement (shoulders, knees) and PMR-like presentation
  • More likely to be RF-negative (seronegative EORA) — anti-CCP remains valuable
  • Higher frequency of male patients compared with young-onset RA
  • Comorbidities (cardiovascular disease, diabetes, renal impairment, osteoporosis) complicate DMARD selection and monitoring
  • Methotrexate remains first-line but requires careful dose adjustment for renal function; hydroxychloroquine and sulfasalazine are well-tolerated in the elderly

Special Considerations in the Elderly

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Corticosteroid Risk

Osteoporosis: DEXA within 3 months; bisphosphonate if T-score <−1.5 or FRAX high risk
Diabetes: Monitor blood glucose; may unmask or worsen type 2 diabetes
Infection: Increased risk of pneumonia, UTI, and herpes zoster
Cataracts and glaucoma: Annual ophthalmological review
Proximal myopathy: Distinguish from PMR stiffness; CK may assist
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Renal Impairment

Methotrexate: Reduce dose or avoid if eGFR <30 mL/min; avoid entirely if eGFR <15 mL/min
NSAIDs: Avoid if possible; if essential, use lowest dose, shortest duration, monitor renal function
Allopurinol (gout): Start low (50–100 mg/day) and titrate slowly
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Infection Risk & Vaccination

Ensure pneumococcal (Prevenar 13 + Pneumovax 23), influenza (annually), and shingles (Shingrix if ≥50) vaccination before starting bDMARDs
Hepatitis B reactivation screening before rituximab or anti-TNF therapy
Consider latent TB screening (QuantiFERON) before biologic initiation

Special Populations

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Pregnancy

Methotrexate: Absolutely contraindicated — teratogenic (Category X). Discontinue ≥3 months before conception in women and ≥3 months before planned fathering in men
Leflunomide: Absolutely contraindicated; cholestyramine washout required before conception
Hydroxychloroquine: Safe and should be continued throughout pregnancy — beneficial for RA and SLE
Sulfasalazine: Generally safe; ensure adequate folate supplementation
Anti-TNF agents: Adalimumab and certolizumab (no Fc — minimal placental transfer) can be continued until 3rd trimester if needed for disease control; other TNF inhibitors discontinued by 20 weeks
NSAIDs: Avoid in 3rd trimester (risk of premature ductus arteriosus closure); limited use in 1st/2nd trimester under specialist guidance
RA and pregnancy: ~60% of RA patients improve during pregnancy; plan conception during stable disease
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Paediatrics

See JIA section above — treatment under paediatric rheumatology guidance
Methotrexate: 10–15 mg/m² PO/SC weekly (max 25 mg); SC preferred for doses >15 mg; anti-emetics as needed
Aspirin (ARF): Reye syndrome risk — use only for ARF management at therapeutic doses with salicylate monitoring
Growth monitoring: Essential for all children on chronic corticosteroids or DMARDs
Septic arthritis in neonates: Staphylococcus aureus and Group B Streptococcus common; hip involvement is a surgical emergency
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Hepatic Impairment

Methotrexate: Avoid if active liver disease or significant hepatic fibrosis; use with extreme caution in history of alcohol excess
Leflunomide: Avoid in significant hepatic impairment
NSAIDs: Risk of hepatotoxicity; monitor LFTs
Regular alcohol consumption: Counsel patients on methotrexate to minimise alcohol; co-prescribe folic acid 5 mg weekly
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Immunocompromised

Biologic DMARDs: Increased risk of serious infections, opportunistic infections (TB, fungi), and herpes zoster — screen and vaccinate before initiation
JAK inhibitors: Higher herpes zoster risk than bDMARDs — recommend Shingrix vaccination before starting
Rituximab: Impairs B-cell function for 6–12 months; monitor immunoglobulin levels; avoid live vaccines for 12 months
Perioperative management: Hold methotrexate for 1–2 weeks around major surgery; hold bDMARDs per rheumatology advice (typically 1–2 dosing cycles before surgery)
Aboriginal and Torres Strait Islander Health

Aboriginal and Torres Strait Islander Australians experience a significantly higher burden of arthritis-related disease, particularly acute rheumatic fever (ARF), rheumatic heart disease (RHD), gout, and osteoarthritis. Systemic barriers to healthcare access compound the clinical burden and require culturally safe, community-centred approaches.

Key Considerations

Acute Rheumatic Fever (ARF)
Rates in Aboriginal and Torres Strait Islander children are 50–100× higher than non-Indigenous Australians. ARF is endemic in the Northern Territory, far north Queensland, and northern Western Australia. The revised Jones Criteria (2015) recognise these communities as "high-risk," lowering the diagnostic threshold (monoarthritis as major criterion, polyarthralgia as minor). The End Rheumatic Heart Disease Centre of Research Excellence (END RHD CRE) has set a target to eliminate RHD in Australia by 2031.
Secondary Prophylaxis
Benzathine penicillin G (BPG) every 28 days for a minimum of 10 years (or until age 21, longer if RHD) is the cornerstone of preventing recurrent ARF and RHD progression. Adherence is a major challenge — injection pain, distance to clinic, and missed appointments are common barriers. RHDAustralia recommends dedicated ARF/RHD registers, recall systems, and community-based delivery models. Where BPG is refused or contraindicated, oral erythromycin 250 mg BD is an alternative, but adherence is even more challenging.
Rheumatology Access
Specialist rheumatology services are extremely limited in remote and regional Australia. Telehealth has expanded access but cannot replace the need for joint injection, imaging, and complex DMARD initiation. Outreach rheumatology clinics (e.g., Top End Rheumatology service in NT) are critical. Culturally safe communication, use of Aboriginal health practitioners as care coordinators, and family-inclusive consultations are essential.
Gout
Gout is significantly more prevalent in Aboriginal and Torres Strait Islander Australians, driven by higher rates of renal impairment, obesity, type 2 diabetes, and metabolic syndrome. Under-treatment and lack of urate-lowering therapy (ULT) initiation is common. Allopurinol should be started at low dose (50–100 mg/day) and titrated with renal function monitoring. Education about chronic ULT use (not just during flares) is essential.
Osteoarthritis
Higher prevalence and earlier onset; joint replacement access is lower despite greater need. Post-operative rehabilitation access in remote communities is limited. Community-based chronic disease self-management programmes (e.g., adapted from the Flinders Model) show promise.
Social Determinants
Overcrowded housing, limited access to clean water, food insecurity, and geographical remoteness all contribute to higher infectious disease burden (including post-streptococcal disease), delayed presentation, and poorer outcomes. Holistic, family-centred models of care that integrate musculoskeletal health with chronic disease management are recommended.
ℹ️
Resources for clinicians: RHDAustralia (rhdaustralia.org.au) provides clinical guidelines, patient resources, and ARF/RHD register tools. The National Aboriginal Community Controlled Health Organisation (NACCHO) supports culturally safe chronic disease management. All patients with confirmed ARF should be notified to the relevant state/territory ARF/RHD register.

📚 References

  1. 1. Gewitz MH, Baltimore RS, Tani LY, et al. Revision of the Jones Criteria for the diagnosis of acute rheumatic fever in the era of Doppler echocardiography. Circulation. 2015;131(20):1806-1818.
  2. 2. Rheumatic Heart Disease Australia (RHDAustralia). Acute Rheumatic Fever and Rheumatic Heart Disease Australian Guidelines. 2nd ed. Darwin: RHDAustralia; 2020.
  3. 3. Aletaha D, Neogi T, Silman AJ, et al. 2010 Rheumatoid arthritis classification criteria: an American College of Rheumatology/European League Against Rheumatism collaborative initiative. Arthritis Rheum. 2010;62(9):2569-2581.
  4. 4. Smolen JS, Landewé RBM, Bergstra SA, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3-18.
  5. 5. Petty RE, Southwood TR, Manners P, et al. International League of Associations for Rheumatology classification of juvenile idiopathic arthritis: second revision, Edmonton, 2001. J Rheumatol. 2004;31(2):390-392.
  6. 6. Ringold S, Angeles-Han ST, Engel ME, et al. 2019 ACR/Arthritis Foundation Guideline for the Screening, Monitoring, and Treatment of Juvenile Idiopathic Arthritis-Associated Uveitis. Arthritis Care Res. 2019;71(12):1514-1525.
  7. 7. Dejaco C, Singh YP, Perel P, et al. 2015 recommendations for the management of polymyalgia rheumatica: a European League Against Rheumatism/American College of Rheumatology collaborative initiative. Ann Rheum Dis. 2015;74(10):1799-1807.
  8. 8. Mathews CJ, Weston VC, Jones A, et al. Bacterial septic arthritis in adults. Lancet. 2010;375(9717):846-855.
  9. 9. Australian Institute of Health and Welfare (AIHW). Arthritis and other musculoskeletal conditions. AIHW; Canberra; 2023.
  10. 10. Carapetis JR, Steer AC, Mulholland EK, Weber M. The global burden of group A streptococcal diseases. Lancet Infect Dis. 2005;5(11):685-694.
  11. 11. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis. Arthritis Care Res. 2021;73(7):924-939.
  12. 12. Royal Australian College of General Practitioners (RACGP). Management of knee osteoarthritis in primary care. RACGP; Melbourne; 2018.
  13. 13. Ytterberg SR, Bhatt DL, Mikuls TR, et al. Cardiovascular and cancer risk with tofacitinib in rheumatoid arthritis. N Engl J Med. 2022;386(4):316-326.
  14. 14. Cannon GW, Mikuls TR. Safety of disease-modifying antirheumatic drugs in older adults with rheumatoid arthritis. Drugs Aging. 2019;36(10):903-914.
  15. 15. National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand. Rheumatic Heart Disease Australia: Guidelines for the diagnosis of acute rheumatic fever and rheumatic heart disease. 2020.
for PBS-listed medicines at participating pharmacies.
Cultural safety
Engagement with Aboriginal Community Controlled Health Organisations (ACCHOs) is essential. Cultural safety training for non-Indigenous clinicians, use of Aboriginal Health Workers and Liaison Officers, and incorporation of traditional healing practices alongside Western medicine improve treatment adherence and outcomes. Avoidance of eye contact, respect for gender-sensitive examination practices, and understanding of sorry business protocols are critical elements of culturally safe care.
Medication adherence
Complex DMARD regimens with frequent monitoring requirements present adherence challenges. Long-acting depot injections (e.g., methotrexate SC) may improve adherence compared to oral regimens. Community pharmacy partnerships through the Indigenous Pharmacy Programmes improve medication management.
Specific conditions
Rheumatic heart disease (RHD) requires secondary prophylaxis with benzathine penicillin G (BPG) 1.2 MU IM every 3–4 weeks for a minimum of 10 years or until age 21 (whichever is longer). RHD registers (e.g., NT RHD Register) facilitate recall and follow-up. The Australian RHD Endgame Strategy targets elimination by 2031.
Referral pathways
Referral through ACCHOs and Aboriginal Hospital Liaison Officers (AHLOs) improves engagement. The Specialist Outreach Assistance Programme provides funded specialist visits to remote communities. NT, WA, and QLD have specific rheumatology outreach programmes targeting Indigenous communities.

📚 References

  1. 1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
  2. 2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
  3. 3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
  4. 4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
  5. 5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
  6. 6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
  7. 7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
  8. 8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
  9. 9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
  10. 10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
  11. 11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
  12. 12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
  13. 13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).
for PBS-listed medicines at participating pharmacies.
Cultural safety
Engagement with Aboriginal Community Controlled Health Organisations (ACCHOs) is essential. Cultural safety training for non-Indigenous clinicians, use of Aboriginal Health Workers and Liaison Officers, and incorporation of traditional healing practices alongside Western medicine improve treatment adherence and outcomes. Avoidance of eye contact, respect for gender-sensitive examination practices, and understanding of sorry business protocols are critical elements of culturally safe care.
Medication adherence
Complex DMARD regimens with frequent monitoring requirements present adherence challenges. Long-acting depot injections (e.g., methotrexate SC) may improve adherence compared to oral regimens. Community pharmacy partnerships through the Indigenous Pharmacy Programmes improve medication management.
Specific conditions
Rheumatic heart disease (RHD) requires secondary prophylaxis with benzathine penicillin G (BPG) 1.2 MU IM every 3–4 weeks for a minimum of 10 years or until age 21 (whichever is longer). RHD registers (e.g., NT RHD Register) facilitate recall and follow-up. The Australian RHD Endgame Strategy targets elimination by 2031.
Referral pathways
Referral through ACCHOs and Aboriginal Hospital Liaison Officers (AHLOs) improves engagement. The Specialist Outreach Assistance Programme provides funded specialist visits to remote communities. NT, WA, and QLD have specific rheumatology outreach programmes targeting Indigenous communities.

📚 References

  1. 1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
  2. 2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
  3. 3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
  4. 4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
  5. 5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
  6. 6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
  7. 7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
  8. 8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
  9. 9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
  10. 10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
  11. 11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
  12. 12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
  13. 13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).