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.
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 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 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.
Comorbidities of RA—particularly cardiovascular disease—must be addressed aggressively.
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.
See also the main article on rheumatoid arthritis.
Video - Practical Pain Management