What is the management of rheumatoid arthritis?

Management of Rheumatoid Arthritis

Methotrexate should be started as first-line therapy as soon as rheumatoid arthritis is diagnosed, with a treatment target of remission or low disease activity. 1

Diagnosis and Initial Assessment

• Early diagnosis and prompt referral to a rheumatologist is crucial for better outcomes
• Rheumatologists should primarily care for RA patients, with multidisciplinary support 2
• Disease activity should be assessed using validated measures:

  State	DAS28	CDAI	SDAI
  Remission	<2.6	≤2.8	≤3.3
  Low activity	2.6-3.2	>2.8-10	>3.3-11
  Moderate activity	3.2-5.1	>10-22	>11-26
  High activity	>5.1	>22	>26

Treatment Algorithm

Step 1: Initial DMARD Therapy

• Start methotrexate (MTX) at 15 mg/week with folic acid 1 mg/day 1, 3
• For MTX contraindications or intolerance, use leflunomide, sulfasalazine, or hydroxychloroquine 2, 1
• Consider short-term glucocorticoids (≤6 months) at low-moderate doses as bridging therapy 2, 1
• Monitor every 1-3 months for disease activity and medication side effects 2, 1

Step 2: Optimization of Initial Therapy (if target not reached by 3-6 months)

• Increase MTX dose up to 25 mg/week 1, 4
• Consider switching from oral to subcutaneous MTX for better bioavailability and fewer GI side effects 4
• If MTX monotherapy fails, consider these options:
  1. For patients without poor prognostic factors: Switch to or add another conventional DMARD 2, 1
  2. For patients with poor prognostic factors: Add a biologic DMARD 2, 1

Step 3: Biologic Therapy (if conventional DMARDs fail)

• TNF inhibitors (adalimumab, certolizumab, etanercept, golimumab, infliximab) are typically first-line biologics 2, 5
• Combine biologics with MTX when possible for enhanced efficacy 2, 5
• If first TNF inhibitor fails, options include:
  • Another TNF inhibitor
  • Biologics with different mechanisms (abatacept, rituximab, tocilizumab) 2
  • JAK inhibitors (tofacitinib) after biologic failure 2

Step 4: Treatment Tapering (for sustained remission)

• Consider tapering only after sustained remission for at least 6 months 1
• Taper in this order: first glucocorticoids, then biologics, then conventional DMARDs 2, 1
• Reduce doses gradually rather than abrupt discontinuation 1

Non-Pharmacological Management

• Regular exercise including aerobic and strength training
• Occupational therapy and assistive devices
• Weight management and smoking cessation
• Patient education on disease self-management
• Regular assessment of vaccination status

Monitoring

• Disease activity: Every 1-3 months until target reached, then every 3-6 months
• Laboratory monitoring: Complete blood count, liver and kidney function tests
• Monitor for medication-specific adverse effects:
  • MTX: Hepatotoxicity, bone marrow suppression, pneumonitis
  • Biologics: Infections (including TB), malignancy 5

Common Pitfalls to Avoid

1. Delayed treatment initiation: Start DMARDs immediately upon diagnosis
2. Inadequate dose optimization: Ensure MTX is optimized (dose/route) before declaring failure
3. Prolonged glucocorticoid use: Limit to <6 months to avoid long-term complications
4. Infrequent monitoring: Regular assessment is crucial for timely treatment adjustments
5. Ignoring comorbidities: Screen for and manage TB, hepatitis, and other infections before starting biologics 5
6. Premature treatment discontinuation: Maintain therapy even after achieving remission, with careful tapering only after sustained remission

The management of RA has evolved significantly, with early aggressive treatment showing improved outcomes in morbidity, mortality, and quality of life. The treat-to-target approach with regular monitoring and timely adjustments is now the standard of care.