From the Guidelines
The treatment of rheumatoid arthritis should begin with methotrexate as the first-line therapy, with a goal of achieving remission or low disease activity, as recommended by the most recent guidelines 1. The treatment approach involves a combination of disease-modifying antirheumatic drugs (DMARDs), biologic agents, and lifestyle modifications.
- Conventional DMARDs, such as hydroxychloroquine, sulfasalazine, and leflunomide, can be used in combination with methotrexate for patients who do not respond adequately to monotherapy.
- Biologic agents, including TNF inhibitors (adalimumab, etanercept, infliximab), IL-6 inhibitors (tocilizumab), T-cell costimulation modulators (abatacept), and JAK inhibitors (tofacitinib, baricitinib), can be added for patients who do not respond to conventional DMARDs.
- Short-term use of corticosteroids, such as prednisone, can help manage flares, while NSAIDs, such as ibuprofen or naproxen, provide symptomatic relief.
- Regular monitoring of disease activity and medication side effects is essential, with treatment adjustments made to achieve remission or low disease activity, as recommended by the American College of Rheumatology guideline for the treatment of rheumatoid arthritis 1.
- Physical therapy, occupational therapy, and lifestyle modifications, including regular exercise and maintaining a healthy weight, complement pharmacological interventions to improve quality of life and reduce disease activity, as supported by the EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs 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 Aspirin, nonsteroidal anti-inflammatory agents and/or low dose corticosteroids may be continued during treatment with leflunomide The combined use of leflunomide with antimalarials, intramuscular or oral gold, D penicillamine, azathioprine, or methotrexate has not been adequately studied
Rituximab is a monoclonal antibody that targets the CD20 antigen expressed on the surface of pre-B and mature B-lymphocytes. B cells are believed to play a role in the pathogenesis of rheumatoid arthritis (RA) and associated chronic synovitis. Treatment with RITUXAN induced depletion of peripheral B lymphocytes, with the majority of patients demonstrating near complete depletion
The treatment options for Rheumatoid Arthritis (RA) include:
- Leflunomide: to reduce signs and symptoms, inhibit structural damage, and improve physical function
- Rituximab: a monoclonal antibody that targets the CD20 antigen expressed on the surface of pre-B and mature B-lymphocytes
- Aspirin: may be continued during treatment with leflunomide
- Nonsteroidal anti-inflammatory agents: may be continued during treatment with leflunomide
- Low dose corticosteroids: may be continued during treatment with leflunomide 2 3
From the Research
Treatment Options for Rheumatoid Arthritis (RA)
The treatment options for Rheumatoid Arthritis (RA) include:
- Disease-modifying antirheumatic drugs (DMARDs) as the first-line treatment, with methotrexate being the initial choice 4, 5, 6, 7
- Nonsteroidal anti-inflammatory drugs (NSAIDs) for pain and inflammation management 5, 8
- Glucocorticoids for controlling pain, inflammation, and stiffness 5, 8
- Biological-response modifiers, such as tumor necrosis factor (TNF)-alpha inhibitors, interleukin-1 inhibitors, and costimulation blockers 5, 7, 8
- Targeted synthetic DMARDs (tsDMARDs) as an alternative to biological DMARDs (bDMARDs) 4, 6
Treatment Approach
The treatment approach for RA involves:
- Early aggressive therapy with a combination of drugs or biological agents 5, 6
- A treat-to-target strategy with a goal of low disease activity or remission 4, 6
- Frequent monitoring of disease activity and escalation of treatment as needed 4, 6
- The possibility of changing within bDMARDs and tsDMARDs, as well as therapeutic de-escalation, in the further course of treatment 4
Medications Used
The medications used to treat RA include:
- Methotrexate, hydroxychloroquine, sulfasalazine, and leflunomide as DMARDs 5, 7
- Infliximab, etanercept, and adalimumab as TNF-alpha inhibitors 5, 7, 8
- Anakinra as a recombinant inhibitor of interleukin-1 5, 8
- Abatacept as a costimulation blocker 5, 8
- Rituximab as a chimeric anti-CD20 monoclonal antibody 5, 7, 8