The diagnosis and management of rheumatoid synovitis

After establishing the diagnosis of rheumatoid arthritis one should determine the extent to which synovitic or structural lesions are responsible for the symptoms. Because structural lesions lack the potential for recovery, a plan should be laid out for their management, by either surgical correction or acceptance of the disability. In regard to the synovitis, one should determine whether it is likely to undergo a spontaneous remission. If a remission seems likely, the physician can manage the disease with a suppressive agent, usually salicylates. If a spontaneous remission seems unlikely and the patient's function is deteriorating, a clinical trial of either gold, hydroxychloroquin, or penicillamine is in order (in conjunction with a suppressive agent). If the first drug fails, one of the others should be tried next. There is no rationale for repeating a trial of one of these drugs if it has previously failed. If all three agents fail to produce a remission, the suppressive agent should be continued, and the physican serves as the patient's "friend" and frequently will be called upon to advise the patient about the need for reconstructive surgery.