What is the recommended treatment for rheumatoid arthritis?

Recommended Treatment for Rheumatoid Arthritis

Methotrexate is the recommended first-line therapy for active rheumatoid arthritis (RA), with dose escalation to at least 15 mg weekly within 4-6 weeks, and regular monitoring every 1-3 months to adjust treatment if targets are not met. 1

Initial Treatment Approach

• Start methotrexate at a dose not less than 10 mg/week, with escalation based on disease severity and patient factors 2
• Increase dose at 6-week intervals up to 20-25 mg/week if inadequate response is observed 1, 2
• Administer oral methotrexate initially, with consideration of switching to subcutaneous route if there is poor compliance, inadequate effectiveness, or gastrointestinal side effects 2
• Add folic acid supplementation (minimum 5 mg weekly, taken at a distance from methotrexate dose) to reduce adverse effects 1, 3

Treatment Targets and Monitoring

• The goal of treatment is remission (SDAI ≤3.3, CDAI ≤2.8) or low disease activity (SDAI ≤11, CDAI ≤10) 1
• Monitor disease activity every 1-3 months in active disease 1
• Mandatory baseline investigations before starting methotrexate:
  • Full blood count
  • Serum transaminases
  • Serum creatinine with creatinine clearance calculation
  • Chest radiograph
  • Hepatitis B and C serology (recommended)
  • Serum albumin (recommended) 2
• Ongoing monitoring should include full blood counts, serum transaminases, and creatinine at least monthly for the first 3 months, then every 4-12 weeks 2

Treatment Escalation

• If no improvement after 3 months of methotrexate, adjust therapy 1
• If target not reached by 6 months, change treatment approach 1
• For patients with inadequate response to methotrexate, consider:
  1. Adding a biologic DMARD (bDMARD) such as TNF inhibitors (e.g., adalimumab) 1, 4
  2. Adding other conventional synthetic DMARDs 1
  3. Switching to another mechanism of action 1

Biologic Therapy Considerations

• Adalimumab (Humira) is indicated for reducing signs and symptoms, inhibiting structural damage progression, and improving physical function in patients with moderately to severely active RA 4
• Adalimumab can be used alone or in combination with methotrexate or other non-biologic DMARDs 4
• Standard dosing for adalimumab is 40 mg subcutaneously every other week 4
• Biologic DMARDs should typically be combined with methotrexate for optimal efficacy 1

Safety Considerations

Methotrexate

• Monitor for hepatotoxicity, bone marrow suppression, and pulmonary toxicity 5
• Drug interactions: NSAIDs, salicylates, probenecid, penicillins, and certain antibiotics may increase methotrexate toxicity 5
• Nausea is a common side effect, more frequently seen with higher starting doses 6

Biologics (e.g., Adalimumab)

• Screen for tuberculosis and hepatitis B before starting biologics 1, 4
• Monitor for serious infections that may lead to hospitalization or death 4
• Be alert for potential malignancies, including lymphoma 4
• Avoid combining different biologics due to increased infection risk 1

Treatment Tapering

• If sustained remission is achieved:
  1. Taper glucocorticoids first
  2. Consider tapering bDMARDs
  3. Continue DMARD therapy if disease activity remains low 1
• Tapering means reducing dose or frequency, not discontinuing therapy 1

Special Considerations

• For seropositive RA with failure of multiple prior therapies, rituximab plus methotrexate may be particularly effective 1
• For patients with lung disease, rituximab may be preferred over methotrexate 1
• For early RA (disease duration <6 months) with low disease activity and without poor prognostic factors, a less aggressive approach may be considered 1
• For established RA (disease duration ≥6 months), more aggressive treatment escalation and earlier biologic therapy may be needed if poor prognostic factors are present 1