Symptom Grade

  • Moderate or severe pain
  • Limiting instrumental activities of daily living and may disable self care
  • Signs of inflammation such as joint swelling
  • Awaking of pain at night
  • Early morning stiffness (>30min)
  • Multiple joints may be affected
Figure of all joints

Management escalation pathway

  • Severity of pain is not a criterium for escalating treatment, treatment will rather be defined by the type and amount of joints affected
  • Escalate analgesics and use NSAID (if not contraindicated)
  • Prednisone (10-20mg) to be started ideally after consultation with rheumatologist
  • Withhold ICPI until resolution of symptoms and tapering of corticoids
  • Intra-articular injections only if infection was ruled out (usually done by treating rheumatologist and to be considered if only one joint is affected)
  • Consider methotrexate/leflunomide/salazopyrine/TNF blocker if steroid refractory or for steroid sparing purposes (experience and not evidence based)

Assessment and Investigations

  • Evaluate pain with visual analogue scale
  • Always do X-ray (consider arthropathy, pre-existing arthropathy, metastasis or baseline evaluation)
  • If possible, try to objectify arthritis (eg by ultrasound or arthrocentesis) and always consider joint aspiration especially when fever or severe inflammation is present (to rule out septic arthritis and crystalarthropathies)
  • Complete rheumatological history regarding differential diagnosis
  • Clinical examination of all joints

Autoimmune panel:

  • ACPA
  • RF
  • ANA (by indirect imunofluorescence) followed by more specific analysis if positive result (according to local practice)
  • ANCA (to be discussed with rheumatologist)
  • Joint biopsy can be done in collaboration with certain centres for scientific purposes

Rheumatology department where joint biopsy is done for scientific purposes

  • Ghent University Hospital
  • Hopital St-Pierre, Brussels
  • Hopital St-Luc, UCL, Brussels
  • Hopital Universitaire de Liège, ULG
  • University Hospital Leuven


ACPA: Anti Citrullinated Antibody
ANCA: Anti Neutrophil Cytoplasmic Antibody
ANF: Anti Nuclear Factor
ICPi: Immune Checkpoint Blockade Inhibition
NSAID: Non Steroidal Anti-Inflammatory Drugs
RF: Rheuma Factor