From the Guidelines
The treatment for Rheumatoid Arthritis (RA) should start with methotrexate (MTX) as the first-line option, with a goal of reaching remission or low disease activity, and therapy should be adjusted based on regular monitoring of disease activity and medication side effects. According to the most recent guidelines, including the 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis 1, treatment decisions should follow a shared decision-making process and should be reevaluated within a minimum of 3 months based on efficacy and tolerability of the DMARD(s) chosen.
Key Treatment Principles
- Therapy with DMARDs should be started as soon as the diagnosis of RA is made 1.
- Treatment should be aimed at reaching a target of sustained remission or low disease activity in every patient 1.
- Monitoring should be frequent in active disease (every 1–3 months); if there is no improvement by at most 3 months after the start of treatment or the target has not been reached by 6 months, therapy should be adjusted 1.
Medication Options
- Conventional DMARDs: methotrexate (MTX), hydroxychloroquine, sulfasalazine, and leflunomide 1.
- Biologic DMARDs: TNF inhibitors (adalimumab, etanercept, infliximab), IL-6 inhibitors (tocilizumab), T-cell costimulation modulators (abatacept), or JAK inhibitors (tofacitinib, baricitinib) may be added for more severe cases 1.
- NSAIDs and short-term low-dose corticosteroids can help manage pain and inflammation while DMARDs take effect 1.
Lifestyle Modifications
- Regular physical therapy, exercise, maintaining a healthy weight, and joint protection techniques are essential complementary approaches 1.
- Treatment should begin early to prevent joint damage, as RA causes progressive joint destruction through chronic inflammation 1.
From the FDA Drug Label
Leflunomide is indicated in adults for the treatment of active rheumatoid arthritis (RA): to reduce signs and symptoms to inhibit structural damage as evidenced by X-ray erosions and joint space narrowing to improve physical function Enbrel is indicated for reducing signs and symptoms, inducing major clinical response, inhibiting the progression of structural damage, and improving physical function in patients with moderately to severely active rheumatoid arthritis (RA)
The treatment for Rheumatoid Arthritis (RA) includes:
- Leflunomide (PO): to reduce signs and symptoms, inhibit structural damage, and improve physical function 2
- Etanercept (SQ): to reduce signs and symptoms, induce major clinical response, inhibit the progression of structural damage, and improve physical function 3 Key points:
- Leflunomide can be used alone or in combination with other medications such as methotrexate, aspirin, nonsteroidal anti-inflammatory agents, and/or low-dose corticosteroids 2
- Etanercept can be initiated in combination with methotrexate (MTX) or used alone 3
From the Research
Treatment Options for Rheumatoid Arthritis (RA)
The treatment for Rheumatoid Arthritis (RA) typically involves a combination of medications and lifestyle changes. The primary goals of treatment are to reduce pain and inflammation, slow or stop joint damage, and improve quality of life.
- Medications:
- Nonsteroidal anti-inflammatory drugs (NSAIDs) to manage pain and inflammation 4
- Disease-modifying antirheumatic drugs (DMARDs) such as methotrexate, hydroxychloroquine, sulfasalazine, and leflunomide to slow disease progression 4, 5, 6
- Biological-response modifiers like infliximab, etanercept, and adalimumab to target specific molecules of the immune system 4
- Glucocorticoids to reduce inflammation and suppress the immune system 4, 5
- Treatment Approach:
- Early aggressive therapy with a combination of drugs or biological agents may be warranted for effective treatment of RA 4, 5
- A treat-to-target strategy aimed at reducing disease activity by at least 50% within 3 months and achieving remission or low disease activity within 6 months 5, 6
- Sequential application of targeted therapies if initial treatment fails 5
- Lifestyle Changes:
- While not explicitly mentioned in the provided studies, lifestyle changes such as regular exercise, a healthy diet, and stress management are often recommended to help manage RA symptoms and improve overall health.
Guidelines and Recommendations
Various guidelines and recommendations have been developed for the treatment of RA, including:
- 2015 American College of Rheumatology Guideline: Provides recommendations on the use of traditional DMARDs, biologic agents, tofacitinib, and glucocorticoids in early and established RA 7
- Treatment Guidelines: Emphasize the importance of starting effective treatment immediately with DMARDs, using effective doses of methotrexate, and rapidly escalating treatment if necessary 6