What is the recommended management approach for rheumatoid arthritis?

Rheumatoid Arthritis Management

The optimal management of rheumatoid arthritis begins with methotrexate (MTX) as first-line therapy, starting at 10-15 mg/week with rapid escalation to 20-25 mg/week within 4-6 weeks, plus short-term glucocorticoids, aiming for >50% improvement within 3 months and target attainment within 6 months. 1

Diagnosis and Initial Evaluation

• Refer urgently for specialist opinion anyone with suspected persistent synovitis of undetermined cause, especially if:

  • Small joints of hands or feet are affected
  • More than one joint is affected
  • Symptom onset occurred ≥3 months before seeking medical advice 2

• Laboratory testing:

  • Rheumatoid factor in patients with synovitis 2
  • Consider anti-cyclic citrullinated peptide (anti-CCP) antibodies if RF negative 2
  • Complete blood count, liver function tests, and serum creatinine 1

Treatment Algorithm

First-Line Therapy

1. Methotrexate initiation:

   • Starting dose: 10-15 mg/week (not less than 10 mg/week) 1, 3
   • Rapid escalation to 20-25 mg/week within 4-6 weeks 1
   • Oral route initially preferred, but consider subcutaneous for better bioavailability 4, 5
   • Add folate supplementation (minimum 5 mg weekly) 3

2. Short-term glucocorticoids:

   • Low-dose prednisone (5-10 mg/day) as bridging therapy 1

Monitoring and Assessment

• Assess disease activity every 1-3 months during active disease 1
• Laboratory monitoring:
  • Complete blood count, liver function tests, serum creatinine at least monthly for first 3 months, then every 4-12 weeks 3
• Target: Remission (DAS28 <2.6) or low disease activity 1
• Expect >50% improvement within 3 months and target attainment within 6 months 1

Treatment Intensification (if target not reached after 3-6 months)

1. If inadequate response to oral MTX:

   • Consider switching to subcutaneous MTX (maintain same dose) 4, 5
   • Continue MTX for at least 6 months if some response is seen within 3 months 5

2. Add additional therapies:

   • Triple therapy: Add sulfasalazine and hydroxychloroquine to MTX 1
   • OR add a biologic agent (TNF inhibitor preferred initially) 1
   • Alternative biologics: abatacept, rituximab, tocilizumab 1, 6

3. For rituximab (when appropriate):

   • Administer as two 1,000 mg IV infusions separated by 2 weeks 6
   • Give with methotrexate 6
   • Administer methylprednisolone 100 mg IV before each infusion 6

Special Considerations

• Early RA (disease duration <6 months):

  • Less aggressive approach may be considered for low disease activity without poor prognostic factors 1
  • Window of opportunity for optimal treatment is within the first year of disease 1

• Established RA (disease duration ≥6 months):

  • More aggressive treatment escalation if poor prognostic factors are present 1

• Safety monitoring:

  • Screen for tuberculosis and hepatitis B before starting biologics 1
  • Monitor immunoglobulin levels before and during rituximab treatment 1

Treatment Goals and Outcomes

• Primary target: Remission (DAS28 <2.6) or low disease activity 1
• Achieving remission within 6 months is critical for preventing radiographic progression 1
• At 1 year, approximately one-third of patients on MTX have no radiographic progression 7
• Even greater effects are seen when MTX is combined with targeted biological therapies 7

Common Pitfalls to Avoid

1. Inadequate MTX dosing: Starting with too low a dose (<10 mg/week) or failing to escalate to 20-25 mg/week 3

2. Premature discontinuation: MTX should be continued for at least 6 months (with some response by 3 months) before declaring treatment failure 5

3. Not considering route of administration: Failing to switch to subcutaneous MTX when oral therapy is inadequate 4, 5

4. Delayed treatment intensification: Missing the window of opportunity within the first year can lead to irreversible joint damage 1

5. Inadequate monitoring: Not performing regular disease activity assessments and laboratory monitoring 1, 3