What is the treatment for rheumatoid arthritis?

Treatment of Rheumatoid Arthritis

Methotrexate is the first-line disease-modifying antirheumatic drug (DMARD) for rheumatoid arthritis treatment, with an initial dose of 15 mg/week and folic acid 1 mg/day, to be started as early as possible, ideally within 3 months of symptom onset. 1

Initial Treatment Approach

• Start methotrexate at 15 mg/week orally with folic acid 1 mg/day
• Escalate to 25-30 mg/week or highest tolerable dose if needed 2
• Consider switching to subcutaneous administration if oral therapy shows insufficient response or poor tolerance 2
• For MTX contraindications or intolerance, use alternative conventional DMARDs:
  • Leflunomide
  • Sulfasalazine
  • Hydroxychloroquine 1

Disease Activity Monitoring

• Assess disease activity using validated measures every 1-3 months:
  • DAS28 (remission <2.6, low 2.6-3.2, moderate 3.2-5.1, high >5.1)
  • CDAI (remission ≤2.8, low >2.8-10, moderate >10-22, high >22)
  • SDAI (remission ≤3.3, low >3.3-11, moderate >11-26, high >26) 1
• Monitor for medication-specific adverse effects (MTX hepatotoxicity, bone marrow suppression, pneumonitis) 1

Treatment Escalation for Inadequate Response

For patients with inadequate response to initial methotrexate therapy:

1. Moderate-to-High Disease Activity: Add a biologic DMARD (bDMARD) or targeted synthetic DMARD (tsDMARD) 1

   • TNF inhibitors are typically first-line biologics (adalimumab, certolizumab, etanercept, golimumab, infliximab) 1
   • Combine biologics with MTX when possible for enhanced efficacy 1

2. If First TNF Inhibitor Fails:

   • Try another TNF inhibitor, OR
   • Switch to biologics with different mechanisms:
     • Abatacept (T-cell co-stimulation modulator)
     • Rituximab (anti-CD20)
     • Tocilizumab (IL-6 inhibitor)
   • Consider JAK inhibitors (tofacitinib) after biologic failure 1

Role of Glucocorticoids

• Consider short-term glucocorticoids (≤6 months) at low-moderate doses as bridging therapy while waiting for DMARDs to take effect 1
• Use at lowest effective dose for shortest time possible (<6 months)
• Long-term use leads to cumulative side effects and should be avoided 1

Important Safety Considerations

For TNF Inhibitors (e.g., Adalimumab):

• Screen for latent tuberculosis before initiating therapy
• Monitor for serious infections that may lead to hospitalization or death
• Be aware of increased risk of lymphoma and other malignancies, particularly hepatosplenic T-cell lymphoma in younger patients 3

For IL-6 Inhibitors (e.g., Tocilizumab):

• Not recommended for concomitant use with biological DMARDs
• Monitor baseline complete blood count and liver function tests
• Avoid initiating if ANC <2000/mm³, platelets <100,000/mm³, or ALT/AST >1.5× ULN 4

Treatment Tapering

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

Non-Pharmacological Interventions

• Occupational therapy and assistive devices to protect joints and improve function
• Dynamic exercise programs incorporating aerobic exercise and strength training
• Patient education on disease management and self-care skills
• Smoking cessation, dental care, weight control, and vaccination status assessment 1

Surgical Options

• Consider surgical interventions (arthroscopy, osteotomy, arthroplasty) for patients with significant functional limitation and failed conservative treatment 1

Early, aggressive treatment with methotrexate and escalation to combination therapy when needed is essential to prevent joint damage and disability in rheumatoid arthritis patients 5.