What is the recommended treatment for rheumatoid arthritis?

Treatment of Rheumatoid Arthritis

Methotrexate (MTX) is the recommended first-line disease-modifying antirheumatic drug (DMARD) for rheumatoid arthritis, with an initial dose of 15 mg/week combined with folic acid 1 mg/day, to be started as early as possible after diagnosis. 1

Initial Treatment Strategy

1. First-line therapy:

   • Start MTX at 15 mg/week with folic acid 1 mg/day
   • Increase to optimal dose of 25 mg/week as tolerated
   • Add short-term low-dose oral glucocorticoids (≤10 mg prednisone equivalent/day) for up to 6 months, tapered as rapidly as clinically feasible 1

2. Pre-treatment evaluation:

   • Laboratory tests: Complete blood count, liver function tests, renal function tests, urinalysis, antinuclear antibodies, rheumatoid factor, and anti-CCP antibodies
   • Imaging: Radiographs of hands and feet to assess for erosions
   • Consider ultrasound or MRI if clinical examination is inconclusive 1

3. MTX administration considerations:

   • Oral route is preferred initially
   • Switch to intramuscular or subcutaneous route if poor compliance, inadequate effectiveness, or gastrointestinal side effects 2
   • Folate supplementation (minimum 5 mg weekly, at a distance from MTX dose) is recommended to reduce side effects 1, 2

Monitoring and Treatment Adjustment

1. Disease activity assessment:

   • Evaluate every 1-3 months using composite measures (DAS28, CDAI, SDAI)
   • Target should be remission or low disease activity within 6 months 1

2. Laboratory monitoring:

   • Full blood count, liver function tests, and creatinine at least monthly for first 3 months, then every 4-12 weeks 2
   • Monitor for adverse effects: nausea (more common with higher starting doses), cytopenia, transaminitis 3

3. Treatment adjustment algorithm:

   • If no improvement after 3 months or target not reached by 6 months, adjust therapy 1
   • Without poor prognostic factors: Change to another conventional synthetic DMARD (csDMARD) such as sulfasalazine or leflunomide
   • With poor prognostic factors: Add a biologic DMARD (bDMARD), such as TNF inhibitors (adalimumab) or other biologics 1

Biologic DMARDs

1. When to consider biologics:

   • After failure of conventional DMARDs like methotrexate 1
   • For patients with poor prognostic factors: high number of swollen/tender joints, elevated ESR/CRP, positive rheumatoid factor and/or anti-CCP antibodies, early erosions 1

2. TNF inhibitor option - Adalimumab (Humira):

   • Indicated for reducing signs and symptoms, inducing major clinical response, inhibiting structural damage progression, and improving physical function 4
   • Dosage: 40 mg subcutaneously every other week
   • Can be used alone or in combination with MTX or other non-biologic DMARDs 4
   • Important safety considerations: increased risk of serious infections (including TB), malignancy 4

Adjunctive Therapies

1. Non-pharmacological approaches:

   • Dynamic exercises and occupational therapy
   • Patient education about disease management and self-care
   • Lifestyle modifications: smoking cessation, dental care, weight control, regular exercise 1

2. Symptomatic relief:

   • NSAIDs may be used for symptomatic relief but should not delay DMARD initiation
   • Consider gastrointestinal, renal, and cardiovascular status before prescribing NSAIDs 1
   • Intra-articular glucocorticoid injections for local symptom relief 1

Common Pitfalls to Avoid

1. Medication errors:

   • Ensure patients understand that MTX is taken weekly, not daily, as daily use has led to fatal toxicity 5
   • Avoid prolonged glucocorticoid use due to increased risk of adverse effects 1

2. Monitoring lapses:

   • Infrequent monitoring of disease activity can lead to inadequate treatment adjustments 1
   • Regular laboratory monitoring is essential to detect toxicity early 5

3. Drug interactions:

   • Use caution with NSAIDs and salicylates as they may reduce tubular secretion of MTX and enhance toxicity 5
   • Oral antibiotics may decrease intestinal absorption of MTX 5
   • Penicillins may reduce renal clearance of MTX 5

By following this treatment algorithm, clinicians can effectively manage rheumatoid arthritis, minimize joint damage, and improve patients' quality of life and functional outcomes.