From the Guidelines
First-line treatment for rheumatoid arthritis (RA) should involve disease-modifying antirheumatic drugs (DMARDs), with methotrexate being the preferred initial option, while for osteoarthritis (OA), non-pharmacological approaches including weight management, physical therapy, and exercise, along with acetaminophen and topical NSAIDs, are recommended. The management of RA and OA requires distinct approaches due to their different pathophysiologies. For RA, the goal is to achieve sustained remission or low disease activity, and therapy with DMARDs should be started as soon as the diagnosis is made, as indicated by the 2019 update of the EULAR recommendations for the management of RA with synthetic and biological disease-modifying antirheumatic drugs 1.
In terms of specific medications for RA, methotrexate is the preferred initial DMARD, with other options including hydroxychloroquine, sulfasalazine, and leflunomide. NSAIDs and low-dose corticosteroids are often used for symptom management. For OA, the first-line treatments are non-pharmacological, including:
- Weight management
- Physical therapy
- Exercise
- Acetaminophen (up to 3000 mg daily)
- Topical NSAIDs
As supported by the 2019 American College of Rheumatology/Athritis Foundation guideline for the management of osteoarthritis of the hand, hip, and knee, strong recommendations are made for exercise, weight loss in patients with knee and/or hip OA who are overweight or obese, and topical nonsteroidal antiinflammatory drugs (NSAIDs) for knee OA 1. Second-line treatments for OA include oral NSAIDs, intra-articular corticosteroid injections, and duloxetine.
Key considerations in the management of both RA and OA include:
- Monitoring disease activity and adjusting therapy as needed
- Considering the potential benefits and harms of different treatments
- Involving patients in the decision-making process and considering their individual needs and preferences
- Using the lowest effective dose of medications and minimizing the risk of adverse effects, as recommended by the NICE guidance on the care and management of osteoarthritis in adults 1.
Overall, the management of RA and OA requires a comprehensive and individualized approach, taking into account the distinct pathophysiology of each condition and the latest evidence-based recommendations. The choice of medication and treatment strategy should be based on the most recent and highest quality evidence, with a focus on minimizing morbidity, mortality, and improving quality of life.
From the Research
First-Line Treatments for Rheumatoid Arthritis (RA)
- Methotrexate is the first-line antirheumatic drug for RA, as it has been shown to relieve pain, reduce the number of affected joints, and provide functional improvement 2, 3.
- Methotrexate is typically started at a dose of 7.5 mg to 25 mg per week, with the option to increase or decrease the dose based on efficacy and tolerability 2, 4.
Second-Line Treatments for Rheumatoid Arthritis (RA)
- If methotrexate monotherapy is ineffective, or when RA is initially severe, adding a TNF-alpha antagonist (such as etanercept or adalimumab) can be beneficial 2, 5.
- The combination of methotrexate and a TNF-alpha antagonist has been shown to be more effective than methotrexate monotherapy in reducing disease activity and slowing joint damage 5.
- A third-line option is to combine rituximab with methotrexate, which has been shown to be effective in patients who have failed TNF-alpha antagonists 2.
Treatment Considerations for Rheumatoid Arthritis (RA)
- Patients with RA have an increased risk of infection due to their disease and therapy, and vaccination status should be checked and screening for relevant infectious diseases should be carried out before starting treatment 6.
- The goal of therapy is to initiate early medical treatment to achieve disease remission or the lowest disease activity possible, and to improve quality of life, prevent bone destruction, and control inflammation 3, 6.