What is the management of rheumatoid arthritis?

Management of Rheumatoid Arthritis

Treatment of rheumatoid arthritis should aim at reaching remission or low disease activity as soon as possible through early diagnosis, prompt initiation of disease-modifying antirheumatic drugs (DMARDs), and a treat-to-target approach with frequent monitoring. 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 2, 1
• Test for rheumatoid factor in patients with suspected RA who have synovitis 2, 1
• Consider measuring anti-cyclic citrullinated peptide antibodies in rheumatoid factor-negative patients, particularly when combination therapy is being considered 2, 1

Treatment Principles

• Implement a treat-to-target approach with tight monitoring every 1-3 months until the target of remission or low disease activity is reached 1, 3
• Early diagnosis and treatment can prevent progression of joint damage in up to 90% of patients, thereby preventing irreversible disability 4
• Treatment should be primarily managed by rheumatologists, with decisions based on shared decision-making between patient and physician 1

Pharmacologic Management

First-Line Therapy

• Methotrexate should be part of the first treatment strategy in patients with active RA, started as soon as the diagnosis is made 1, 5
  • The optimal dose is 25 mg weekly in combination with glucocorticoids; 40-50% of patients reach remission or low disease activity with this regimen 4
  • Methotrexate is indicated for severe, active rheumatoid arthritis that has had insufficient response to first-line therapy including full-dose NSAIDs 5

Alternative First-Line DMARDs

• When methotrexate is contraindicated or not tolerated, consider leflunomide, sulfasalazine, or injectable gold as alternative first-line DMARDs 1, 6
• Hydroxychloroquine may also be considered as an alternative DMARD 6

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 to minimize long-term side effects 1

Biologic and Targeted Synthetic DMARDs

• If treatment target is not achieved with first DMARD strategy and poor prognostic factors are present, consider adding a biologic DMARD 1, 4
• Tumor necrosis factor (TNF) inhibitors (adalimumab, certolizumab, etanercept, golimumab, infliximab) are typically the first biologic agents used and should be combined with methotrexate 1, 7
• Adalimumab is indicated for reducing signs and symptoms, inducing major clinical response, inhibiting structural damage progression, and improving physical function in patients with moderately to severely active RA 7
• If a first TNF inhibitor fails, consider another TNF inhibitor, abatacept, rituximab, or tocilizumab 1
• JAK inhibitors represent newer targeted synthetic DMARDs that can be effective in patients who fail traditional DMARDs 4, 6

Refractory Disease

• For refractory severe RA or when biologics are contraindicated, consider azathioprine, cyclosporine A, or in exceptional cases, cyclophosphamide 1

Monitoring and Treatment Adjustment

• Aim to achieve at least 50% reduction in disease activity within 3 months and remission or low disease activity within 6 months 4
• 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

Important Considerations and Precautions

• Patients treated with TNF inhibitors like adalimumab are at increased risk for developing serious infections that may lead to hospitalization or death 7
• Screen for latent tuberculosis before starting biologic therapy and monitor for development of infections during treatment 7
• Be aware of potential malignancy risks with biologic therapies, particularly lymphoma and other malignancies in children and adolescents 7
• A multidisciplinary approach involving rheumatologists, nurses, physical and occupational therapists, and psychologists optimizes outcomes 1