What are the medical treatments for Rheumatoid Arthritis (RA)?

From the Guidelines

Medical treatment for rheumatoid arthritis typically involves a combination of medications to reduce inflammation, prevent joint damage, and improve quality of life, with the cornerstone of treatment being disease-modifying antirheumatic drugs (DMARDs), as recommended by the 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis 1. The treatment approach should follow a shared decision-making process, with treatment decisions reevaluated within a minimum of 3 months based on efficacy and tolerability of the DMARD(s) chosen.

• Key principles of treatment include:
  • Early evaluation, diagnosis, and management of RA
  • Treatment decisions based on a shared decision-making process
  • Reevaluation of treatment decisions within a minimum of 3 months
  • Use of DMARDs, including conventional synthetic DMARDs (csDMARDs), biologic DMARDs (bDMARDs), and targeted synthetic DMARDs (tsDMARDs)
  • Monitoring of disease activity and medication side effects
• The first-line treatment option is methotrexate, usually started at 7.5-10mg weekly and potentially increased to 20-25mg weekly as needed, supplemented with folic acid (1mg daily) to reduce side effects.
• For patients with moderate to severe disease or those who don't respond adequately to methotrexate alone, biologic DMARDs like TNF inhibitors (adalimumab, etanercept, infliximab), IL-6 inhibitors (tocilizumab), T-cell costimulation modulators (abatacept), or JAK inhibitors (tofacitinib, baricitinib) may be added, as recommended by the 2020 EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2019 update 1.
• Symptom management may include NSAIDs like ibuprofen (400-800mg three times daily) or naproxen (500mg twice daily) for pain and inflammation, and low-dose corticosteroids like prednisone (5-10mg daily) may be used temporarily during disease flares or as bridge therapy while waiting for DMARDs to take effect.
• Treatment should begin early after diagnosis to prevent irreversible joint damage, as these medications work by modulating the immune system to reduce the autoimmune response that causes joint inflammation and destruction, as emphasized by the 2020 EULAR recommendations 1.
• Regular monitoring of disease activity and medication side effects is essential for optimal management, with adjustments to treatment made as needed to achieve the target of sustained remission or low disease activity.

From the FDA Drug Label

RITUXAN, in combination with methotrexate, is indicated for the treatment of adult patients with moderately- to severely-active rheumatoid arthritis who have had an inadequate response to one or more TNF antagonist therapies.

Medical Treatments for Rheumatoid Arthritis (RA):

• Rituximab (RITUXAN) in combination with methotrexate for adult patients with moderately- to severely-active RA who have had an inadequate response to one or more TNF antagonist therapies 2.
• The treatment is administered via intravenous infusion.
• Patients should be premedicated before each infusion and monitored for severe infusion-related reactions.
• Complete blood counts (CBC) with differential and platelet counts should be obtained at two to four month intervals during RITUXAN therapy.

From the Research

Medical Treatments for Rheumatoid Arthritis (RA)

• The primary treatment for RA includes disease-modifying antirheumatic drugs (DMARDs), such as methotrexate (MTX) 3, 4, 5, 6.
• MTX is often used in combination with other DMARDs, including hydroxychloroquine (HCQ) and sulfasalazine, to achieve better results 3, 4, 7.
• The combination of MTX, HCQ, and sulfasalazine has been shown to be effective in patients with a suboptimal response to MTX 4, 7.
• Other treatment options include the use of biologic DMARDs, such as tumor necrosis factor blockers (e.g., etanercept and infliximab), and targeted synthetic DMARDs (tsDMARDs) 3, 5, 6.
• Treatment guidelines recommend starting with effective treatment immediately, using DMARDs to reduce disability, and rapidly escalating treatment if necessary 5, 6.
• The treat-to-target strategy aims to achieve low disease activity or remission by frequently monitoring disease activity and escalating treatment 5, 6.
• The therapeutic aim is remission, defined as a simplified disease activity score index (SDAI) of ≤3.3 or fulfilling the Boolean criteria, with a first evaluation of response due after 12 weeks 6.