rheumatological management

rheumatological management

; inverted-pyramid approach; step-down bridge paradigm for rheumatological disease management, i.e. aggressive early symptom management (with disease-modifying antirheumatic drugs) to suppress inflammation, establish and maintain disease remission and limit/prevent irreversible joint damage (Table 1)
Table 1: 'Step-down' management paradigm for the treatment of rheumatological and inflammatory joint disease
Initial approach to all cases presenting with rheumatological or inflammatory joint disease1. Early diagnosis
2. Start DMARD therapy within 3 months of diagnosis ± NSAID ± local/systemic steroid
3. Ongoing patient education and rehabilitation
Adequate response to 1, 2, 3 above:
Monitor; consider step-down of drug treatments
Inadequate response:
4. Change or add in other DMARDs
Adequate response to 4 above:
Monitor; consider step-down of drug treatments
Inadequate response to increased DMARDs:
5. Add in biological drugs
Adequate response to 5 above:
Monitor; consider step-down of drug treatments
Inadequate response to biological drugs:
6. Surgical management of joint degeneration

DMARD, disease-modifying antirheumatic drug; NSAID, non-steroidal anti-inflammatory drug.