Initial Treatment for Rheumatoid Arthritis
Methotrexate (MTX) should be initiated as the first-line disease-modifying antirheumatic drug (DMARD) for patients with rheumatoid arthritis, with an initial dose of 15 mg/week along with folic acid 1 mg/day. 1
Initial Treatment Approach
First-Line Therapy
- Start with methotrexate at 15 mg/week orally (not less than 10 mg/week) 1, 2
- Add folic acid supplementation at 5 mg weekly (taken at a different time than MTX) to reduce side effects 1, 2
- Assess disease activity using validated composite measures (DAS28, CDAI, or SDAI) every 1-3 months 1
- Continue MTX for at least 6 months to accurately assess efficacy (as long as some response is seen within 3 months) 1, 3
Dose Titration
- If inadequate response is observed, increase MTX dose by 2.5 mg every 2 weeks 1, 4
- Maximum dose typically ranges from 20-25 mg/week 1, 2
- Consider switching to subcutaneous administration if:
Monitoring and Safety
Before starting MTX, obtain 1, 2:
- Complete blood count
- Liver function tests (transaminases)
- Serum creatinine with creatinine clearance calculation
- Chest radiograph
- Hepatitis B and C serology (recommended)
- Serum albumin (recommended)
Regular monitoring during treatment 1, 2:
- Complete blood count
- Liver function tests
- Serum creatinine
- Monitor monthly for first 3 months, then every 4-12 weeks
Treatment Response Assessment
- Target should be remission or low disease activity within 6 months 1
- Disease activity thresholds 1:
- Remission: DAS28 <2.6, CDAI ≤2.8, SDAI ≤3.3
- Low activity: DAS28 2.6-3.2, CDAI >2.8-10, SDAI >3.3-11
- Moderate activity: DAS28 3.2-5.1, CDAI >10-22, SDAI >11-26
- High activity: DAS28 >5.1, CDAI >22, SDAI >26
Adjunctive Therapies
- For acute flares during initial treatment, consider 1:
- NSAIDs (with PPI if appropriate)
- Short-term oral corticosteroids (prednisolone 30-35 mg/day for 3-5 days)
- Intra-articular corticosteroid injections for monoarticular flares
Non-Pharmacological Interventions
- Patient education about the disease and treatment options 1
- Dynamic exercise programs incorporating aerobic exercise and strength training 1
- Occupational therapy and assistive devices 1
- Lifestyle modifications: weight control, smoking cessation, dental care 1
Clinical Pearls and Pitfalls
- MTX's therapeutic effect typically begins within 3-6 weeks, with continued improvement for up to 12 weeks or more 1, 5
- Gastrointestinal side effects (particularly nausea) are the most common adverse effects and may be dose-related 5, 4
- Starting at 15 mg/week rather than lower doses may provide faster disease control without significantly increased toxicity 2, 4
- MTX is the cornerstone therapy with superior efficacy profile and extensive clinical experience 6, 7
- If MTX monotherapy is inadequate after optimal dosing, consider combination therapy with a TNF inhibitor or other biologics 1, 6
By following this approach, you can optimize the chance of achieving disease control while minimizing the risk of side effects in patients with rheumatoid arthritis.