What is the management of rheumatoid arthritis?

Management of Rheumatoid Arthritis

Early, aggressive treatment of rheumatoid arthritis with disease-modifying antirheumatic drugs (DMARDs) is essential to prevent joint damage, improve quality of life, reduce comorbidities, and enhance survival. 1

Diagnosis and Early Referral

• Refer patients with suspected persistent synovitis urgently for specialist rheumatologist evaluation, even with normal acute-phase reactants or negative rheumatoid factor, especially when small joints of hands/feet are affected, multiple joints are involved, or symptoms have persisted for ≥3 months 1
• Test for rheumatoid factor in patients with suspected RA who have synovitis 1
• Consider measuring anti-cyclic citrullinated peptide antibodies in rheumatoid factor-negative patients, particularly when combination therapy is being considered 1

Treatment Principles

• Treatment should aim at reaching a target of remission or low disease activity as soon as possible in every patient 1
• Treatment should be adjusted through frequent monitoring (every 1-3 months) until the target is reached 1
• Rheumatologists should primarily care for patients with RA, with treatment decisions based on shared decision-making between patient and physician 1

Pharmacologic Management

First-Line Therapy

• Methotrexate (MTX) should be part of the first treatment strategy in patients with active RA 1
• Start MTX as soon as the diagnosis of RA is made 1
• Optimal dosing of MTX is 25 mg weekly, in combination with glucocorticoids 2
• When MTX is contraindicated or not tolerated, consider leflunomide, sulfasalazine, or injectable gold as alternative first-line DMARDs 1

Glucocorticoids

• Low to moderately high doses of glucocorticoids added to DMARD therapy provide benefit as initial short-term treatment 1
• Taper glucocorticoids as rapidly as clinically feasible 1

Biologic DMARDs and Advanced Therapies

• If treatment target is not achieved with first DMARD strategy and poor prognostic factors are present, consider adding a biologic DMARD 1
• Tumor necrosis factor (TNF) inhibitors (adalimumab, certolizumab, etanercept, golimumab, infliximab) are typically the first biologic agents used, and should be combined with MTX 1, 3
• If a first TNF inhibitor fails, consider another TNF inhibitor, abatacept, rituximab, or tocilizumab 1
• For refractory severe RA or when biologics are contraindicated, consider azathioprine, cyclosporine A, or in exceptional cases, cyclophosphamide 1
• Newer targeted synthetic DMARDs include JAK inhibitors, which can be effective for patients who fail traditional therapies 4

Monitoring and Treatment Adjustment

• Assess disease activity regularly using validated measures 2
• Aim for at least 50% reduction in disease activity within 3 months and remission or low disease activity within 6 months 2
• If treatment targets are not met, adjust therapy sequentially until goals are achieved 2
• Consider tapering biologic DMARDs in patients who achieve persistent remission, especially if combined with a synthetic DMARD 1
• In cases of sustained long-term remission, cautious reduction of synthetic DMARD dosage may be considered 1

Non-Pharmacologic Management

• Patient education about disease pathophysiology, self-management skills, and joint protection principles improves health outcomes and physical function 1
• Occupational therapy provides benefits through joint protection instruction and prescription of assistive devices, orthotics, and splints 1
• Dynamic exercise programs incorporating both aerobic exercise and progressive resistance training improve fitness and strength without exacerbating disease activity 1
• A multidisciplinary approach involving rheumatologists, nurses, physical and occupational therapists, and psychologists optimizes outcomes 1

Special Considerations

• Screen for tuberculosis and hepatitis B/C before initiating biologic therapy 5
• Monitor for potential adverse effects of medications, including infections, liver toxicity, and bone marrow suppression 3, 6
• Be aware that TNF inhibitors and other biologics carry risks of serious infections and potential malignancy 3
• Early diagnosis and treatment can prevent progression of joint damage in up to 90% of patients 2