What are the treatment options for rheumatoid arthritis?

Rheumatoid Arthritis Treatment Options

Methotrexate (MTX) should be the first-line disease-modifying antirheumatic drug (DMARD) for all newly diagnosed rheumatoid arthritis patients, with an initial dose of 15 mg/week plus folic acid 1 mg/day, started as early as possible, ideally within 3 months of symptom onset. 1

Treatment Goals and Strategy

• The primary aim of treatment is to achieve remission or low disease activity, preventing joint damage and disability
• Early referral to a rheumatologist (within 6 weeks of symptom onset) is crucial for optimal outcomes
• Disease activity should be assessed every 1-3 months using composite measures
• Target should be remission or low disease activity within 6 months 1

First-Line Treatment

• MTX is the anchor drug for RA management
• Initial dosing: 15 mg/week with folic acid 1 mg/day
• Can be increased as needed based on response
• MTX can be administered orally or subcutaneously (SC route offers better bioavailability) 1, 2

Treatment Escalation

If MTX monotherapy is insufficient after 3-6 months:

Option 1: Conventional DMARD Combination

• Add hydroxychloroquine and sulfasalazine to MTX (triple therapy) 1
  • Hydroxychloroquine: 200-400 mg daily 3
  • Sulfasalazine: Start at 500 mg daily, increase gradually to 2-3 g/day 1

Option 2: Add Biologic DMARD

• TNF inhibitors (etanercept, adalimumab, infliximab)
• IL-6 receptor antagonists (tocilizumab)
• T-cell co-stimulation modulators (abatacept)
• Anti-CD20 monoclonal antibodies (rituximab) 1

For example, tocilizumab is indicated for moderately to severely active RA in patients with inadequate response to one or more DMARDs 4

Management of Acute Flares

• Oral corticosteroids: Prednisolone 30-35 mg/day for 3-5 days
• NSAIDs: Use at minimum effective dose for shortest time possible
• Intra-articular corticosteroid injections for monoarticular flares 1

Medication Tapering

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

Monitoring

• Before starting treatment: Complete blood count (CBC) and liver function tests
• Do not initiate treatment if:
  • Absolute neutrophil count (ANC) < 2000/mm³
  • Platelet count < 100,000/mm³
  • ALT or AST > 1.5 times upper limit of normal 1, 4
• Regular monitoring using composite disease activity measures:

  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

Important Considerations

• Avoid combining biologic DMARDs due to increased immunosuppression and infection risk 4
• Screen for tuberculosis before starting biologic therapy 1
• For patients who don't respond to initial biologic therapy, switch to an alternative biologic with a different mechanism of action 1
• Consider tocilizumab or abatacept in seronegative patients after inadequate response to TNF inhibitors 1

Non-Pharmacological Interventions

• Dynamic exercises incorporating aerobic exercise and strength training
• Occupational therapy and assistive devices to protect joints
• Patient education on disease management and self-care
• Weight loss, regular exercise, and smoking cessation 1

Special Populations

For patients with liver disease:

• Hydroxychloroquine is considered the safest DMARD in cirrhosis (200-400 mg daily)
• Sulfasalazine is generally safe in stable cirrhosis
• TNF inhibitors can be safely administered in patients with cirrhosis, with etanercept possibly having a better hepatic safety profile 1