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Rheumatoid Arthritis (RA) - Treatment

The treatment of rheumatoid arthritis (RA) has evolved dramatically during the past 30 years, perhaps more so than for any of the other rheumatic diseases.It is truly remarkable that rheumatologists now have more than 20 approved conventional or biologic DMARDs from which to choose. However, despite all these terrific DMARD options, the most important paradigm shift for the treatment of RA has been the realization that patients should be treated early and with a target of low disease activity or remission.

Disease-Modifying Anti-rheumatic Drugs

Methotrexate, Sulfasalazine, Hydroxychloroquine, Leflunomide, and Azathioprine

By definition, a DMARD has the ability to change the course of RA (for the better). The most rigorous application of this definition requires RCTs to show that a DMARD has the ability not only to change the clinical course of the disease but also to decrease or halt the radiographic progression.

The type of DMARD therapy the patient receives is not as important as ensuring that the treatment meets the disease activity target.

The initial DMARD and the cornerstone of therapy for most patients is methotrexate.

Many very effective biologic DMARDs are available; essentially all DMARDs are more effective when administered with methotrexate.

Nonsteroidal anti-inflammatory drugs may provide useful symptom control but are rarely indicated without concomitant use of DMARDs.

Biologic Disease-Modifying Anti-rheumatic Drugs

Because of their often quick onset of action, particularly with the TNF inhibitors and tocilizumab, and their ability to retard radiographic progression of disease, they are increasingly used earlier and more often in persons with RA. The challenge for clinicians is to appropriately integrate conventional and biologic therapies and to use biologic agents when necessary but to make sure the much less expensive conventional therapies have been optimized.

Glucocorticoids are rapidly effective DMARDs but have adverse effects. Therefore they should be used only with other DMARDs and ideally only as a bridge to effective DMARD therapy.

Other Conventional Disease-Modifying Anti-rheumatic Drugs

Azathioprine

Azathioprine (AZA), 50 to 200 mg/day, has been used to treat RA for more than 50 years. Because it has been a generic drug for many years, little recent research has been performed on AZA. Although clearly it is not a first-line DMARD in contemporary RA treatment, AZA is most commonly used as a substitute for MTX when contraindications or intolerance to MTX exist.

The ubiquitous comorbidities of RA—particularly cardiovascular disease—must be addressed aggressively.

The problem with RA has been the lack of valid reproducible measures of disease activity and remission that can be routinely measured and followed up on in the clinic. Unfortunately, no single examination finding or laboratory test satisfactorily measures disease activity in persons with RA.

Busy clinicians rarely have time to document disease activity in more than 60 tender and swollen joints or wait for laboratory test results to make treatment decisions during a patient’s visit. Therefore measures that simplify this process as much as possible are being embraced, including measures that limit the joints that are examined to 28 (Disease Activity Score in 28 joints, [DAS28]) do not require laboratory tests (Clinical Disease Activity Index), or are entirely dependent on patient-reported data (Routine Assessment Patient Index Data). A high correlation exists among these measures, and thus currently in the clinic it is very important that disease activity be measured and less important which measure is used.

Instruments used to measure Rheumatoid Arthritis Disease Activity

Instrument

Score Range

Remission

Low

Moderate

High

Disease Activity Score in 28 joints (DAS28)

0-9.4

≤2.6

≤3.2

>3.2 and ≤5.1

>5.1

Simplified Disease Activity Index (SDAI)

0.1-86.0

≤3.3

≤11

>11 and ≤26

>26

Clinical Disease Activity Index (CDAI)

0-76.0

≤2.8

≤10

>10 and ≤22

>22

Rheumatoid Arthritis Disease Activity Index (RADAI)

0-10

≤1.4

<2.2

2.2 and ≤4.9

>4.9

Patient Activity Scale (PAS or PASII)

0-10

≤1.25

<1.9

≥1.9 and ≤5.3

>5.3

Routine Assessment Patient Index Data (RAPID)

0-30

≤1

<6

≥6 and ≤12

>12

The new ACR/EULAR remission criteria: rationale for developing new criteria for remission

Adjuncts to Medications

Patient Education

It is clearly important for patients to take an active role in the management of their chronic disease. The more patients understand their disease and medications, the more control they feel they have over the entire situation.

Pain Control

If patients with RA are treated early and effectively with DMARDs and therapy is escalated to achieve excellent control of the active components of disease, the need for specific pain medications, particularly narcotics, can be minimized. If pain is a major problem, the first thing to do is review the DMARD program and modify it to achieve maximum control of any active synovitis.

Rest and/or Exercise and Activities of Daily Living

Education and supervision of a patient by trained professionals regarding the importance of finding the best balance of rest and exercise for inflamed joints is essential.

Treatment of Rheumatoid Arthritis Comorbidities and the Interactions of Rheumatologists with Primary Care Physicians

The best possible outcomes for patients with RA can be achieved only with a carefully orchestrated collaboration between PCPs and rheumatologists. On the one hand, the ever-increasing complexity of RA management options, combination therapies, and possible toxicities of therapy have made it increasingly essential that all patients with RA be treated by rheumatologists. Good-quality evidence shows that patients with RA are more likely to be taking DMARDs, as well as combination DMARDs, and are happier with their care when they are treated by rheumatologists. On the other hand, the realization of the critical nature of the comorbidities associated with RA, especially cardiovascular disease, make ongoing engagement of a PCP essential to produce optimal outcomes.

Role of Primary Care Physicians in Treating Rheumatoid Arthritis:

  • Monitor and aggressively treat cardiovascular risk factors
  • Monitor and treat/prevent osteoporosis
  • Recognize toxicities of RA medications and initiate appropriate and timely workup
  • Recognize the risks for infections and ensure immunization status is current

See also the main article on rheumatoid arthritis.


PubMed

UpToDate


Video - Drug Treatment

Video - Practical Pain Management


Arthritis Foundation

Medscape

EULAR Recommendations

ACR Guidelines

NHS UK