Treatment Options for Rheumatoid Arthritis
Methotrexate should be initiated as the first-line disease-modifying antirheumatic drug (DMARD) for rheumatoid arthritis treatment, with an initial dose of 15 mg/week plus folic acid supplementation. 1
Initial Treatment Approach
First-Line Therapy
- Methotrexate (MTX) is the anchor drug and should be started as early as possible, ideally within 3 months of symptom onset 1
- Initial dose: 15 mg/week with folic acid 1 mg/day
- Can be administered orally or subcutaneously (subcutaneous route offers better bioavailability)
- Regular monitoring of complete blood count and liver function tests is required
Alternative First-Line Options (if MTX contraindicated)
- Hydroxychloroquine: 200-400 mg daily 2
- Safest DMARD for patients with liver disease
- Requires regular ophthalmologic monitoring
- Sulfasalazine: Start at 500 mg daily, gradually increase to 2-3 g/day 1
- Monitor liver function tests every 1-3 months initially
Treatment Escalation Algorithm
Step 1: Inadequate response to MTX monotherapy after 3 months
- Add hydroxychloroquine and sulfasalazine to MTX (triple therapy) 3, 1
- OR add a biologic DMARD to MTX 3
- TNF inhibitors (adalimumab, etanercept, infliximab)
- IL-6 receptor antagonists (tocilizumab)
- T-cell co-stimulation modulator (abatacept)
- Anti-CD20 monoclonal antibody (rituximab)
Step 2: Inadequate response to combination therapy
- Switch to an alternative biologic with a different mechanism of action 3
- Consider tocilizumab or abatacept in patients who are seronegative for rheumatoid factor after inadequate response to TNF inhibitors 3
Glucocorticoid Use
- Short-term use during disease flares: prednisolone 30-35 mg/day for 3-5 days 1
- Bridge therapy while waiting for DMARDs to take effect
- Long-term use (beyond 1-2 years) should be avoided due to risks including cataracts, osteoporosis, fractures, and cardiovascular disease 3
- Intra-articular injections for monoarticular flares 1
Treatment Targets and Monitoring
- Assess disease activity every 1-3 months using composite measures (DAS28, CDAI, SDAI) 1
- Target should be remission or low disease activity within 6 months 1
- Disease activity thresholds:
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
Medication Tapering
- Consider tapering 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
Special Considerations
- Avoid combining biologic DMARDs due to increased risk of infections 4
- Obtain baseline complete blood count and liver function tests before starting treatment 4
- Tocilizumab should not be initiated in patients with ANC below 2000/mm³, platelet count below 100,000/mm³, or ALT/AST above 1.5 times ULN 4
- Screen for tuberculosis before starting biologic therapy 3
Non-Pharmacological Interventions
- Dynamic exercise programs incorporating aerobic exercise and strength training 1
- Occupational therapy and assistive devices to protect joints 1
- Patient education on disease management and self-care 1
- Smoking cessation, dental care, weight control, and vaccination assessment 1
Common Pitfalls to Avoid
- Delaying DMARD therapy - early treatment is crucial to prevent joint damage
- Using inadequate MTX dosing - ensure appropriate dose escalation
- Failing to monitor disease activity regularly - prevents timely treatment adjustments
- Prolonged glucocorticoid use - increases risk of adverse effects
- Not screening for tuberculosis before biologic therapy - increases risk of reactivation
- Combining multiple biologic DMARDs - significantly increases infection risk
The most recent evidence strongly supports early, aggressive treatment with DMARDs, particularly methotrexate as the cornerstone therapy, with a treat-to-target approach aiming for remission or low disease activity to improve long-term outcomes and prevent joint damage.