What is the recommended treatment for rheumatoid arthritis?

Treatment for 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, escalating as needed, and should be started as early as possible, ideally within 3 months of symptom onset. 1

Initial Treatment Approach

First-Line Therapy

• Start with methotrexate 15 mg/week orally with folic acid 1 mg/day supplementation 1, 2
• Adjust dose upward to 20-25 mg/week at 6-week intervals if inadequate response 1
• Consider switching to subcutaneous administration if:
  • Inadequate response to oral therapy
  • Gastrointestinal side effects
  • Poor compliance 1

Monitoring Requirements

• Before starting MTX, obtain: 1, 2

  • Complete blood count with differential
  • Liver function tests (transaminases)
  • Serum creatinine and creatinine clearance
  • Chest X-ray
  • Hepatitis B and C serology
  • Serum albumin
  • Tuberculosis screening (if biologic therapy is anticipated)

• During treatment: 1, 2

  • Monthly monitoring of blood counts, liver and renal function for first 3 months
  • Then every 1-3 months thereafter
  • Disease activity assessment every 1-3 months using composite measures (DAS28, CDAI, or SDAI)

Treatment Escalation

Inadequate Response to MTX Monotherapy

If target of remission or low disease activity is not achieved within 3-6 months, consider: 1

1. Triple Therapy Option:

   • Add hydroxychloroquine (200-400 mg daily) and sulfasalazine (starting at 500 mg daily, increasing to 2-3 g/day) to MTX 1, 3, 4
   • This combination has shown superior efficacy compared to MTX alone 4

2. Biologic DMARD Option:

   • Add a biologic agent to MTX, options include: 1
     • TNF inhibitors (etanercept, adalimumab, infliximab, etc.)
     • IL-6 receptor antagonists (tocilizumab)
     • T-cell co-stimulation modulators (abatacept)
     • Anti-CD20 monoclonal antibodies (rituximab)

3. Switching Biologics:

   • If first biologic fails, switch to a biologic with a different mechanism of action 1
   • Consider tocilizumab or abatacept in seronegative patients after inadequate response to TNF inhibitors 1

Acute Flare Management

• Short-term options: 1
  • Colchicine: Loading dose of 1 mg followed 1 hour later by 0.5 mg on day 1
  • NSAIDs with proton pump inhibitor (use with caution due to drug interactions with MTX) 1, 2
  • Oral corticosteroids: 30-35 mg/day prednisolone equivalent for 3-5 days
  • Intra-articular corticosteroid injection for monoarticular flares

Special Considerations

Medication Safety

• Methotrexate: 1, 2

  • Avoid in pregnancy and breastfeeding
  • Use with caution with NSAIDs (may increase MTX toxicity)
  • Monitor for hepatotoxicity, bone marrow suppression, and pulmonary toxicity
  • Reduce dose in renal impairment

• Hydroxychloroquine: 1, 3

  • Safest DMARD in liver disease
  • Requires regular ophthalmologic monitoring
  • Standard dose 200-400 mg daily

• Sulfasalazine: 1

  • Generally safe in stable liver disease
  • Monitor liver function tests every 1-3 months initially

Medication Tapering

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

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

Treatment Target

• Aim for remission or low disease activity within 6 months 1
• Assess disease activity using validated measures: 1
  • Remission: DAS28 <2.6, CDAI ≤2.8, or SDAI ≤3.3
  • Low activity: DAS28 2.6-3.2, CDAI >2.8-10, or SDAI >3.3-11