What is the treatment for a new case of Rheumatoid Arthritis (RA)?

From the Guidelines

For a new case of rheumatoid arthritis (RA), treatment should begin promptly with a disease-modifying antirheumatic drug (DMARD), typically methotrexate as first-line therapy at 7.5-25 mg once weekly, along with folic acid supplementation (1 mg daily) to reduce side effects, as recommended by the most recent guidelines 1. The goal of treatment is to achieve sustained remission or low disease activity (LDA) in every patient, with frequent monitoring (every 1-3 months) and adjustments to therapy as needed if there is no improvement by 3 months or the target has not been reached by 6 months 1. Key points to consider in the management of RA include:

• Initial treatment with DMARDs should be started as soon as the diagnosis of RA is made, with methotrexate being the preferred first-line option due to its efficacy and safety profile 1.
• For patients with a contraindication to methotrexate (or early intolerance), alternatives such as leflunomide or sulfasalazine should be considered as part of the first treatment strategy 1.
• Short-term use of NSAIDs and possibly low-dose prednisone may be used for symptom relief and as a bridge therapy until DMARDs take effect, typically tapered within 3-6 months.
• Regular monitoring includes clinical assessments and laboratory tests to guide treatment adjustments, with the aim of preventing joint damage, maintaining function, and potentially leading to remission by interrupting the inflammatory cascade that causes joint destruction in RA 1. In cases where methotrexate is not effective or tolerated, combination therapy or biologics like TNF inhibitors may be considered, emphasizing the importance of a treat-to-target approach to minimize disease activity and achieve the predefined target of low disease activity or remission 1.

From the FDA Drug Label

Enbrel is indicated for reducing signs and symptoms, inducing major clinical response, inhibiting the progression of structural damage, and improving physical function in patients with moderately to severely active rheumatoid arthritis (RA). Enbrel can be initiated in combination with methotrexate (MTX) or used alone. Leflunomide is indicated in adults for the treatment of active rheumatoid arthritis (RA): to reduce signs and symptoms to inhibit structural damage as evidenced by X-ray erosions and joint space narrowing to improve physical function

The treatment for a new case of Rheumatoid Arthritis (RA) may include:

• Etanercept (Enbrel): 50 mg weekly, which can be initiated in combination with methotrexate (MTX) or used alone 2
• Leflunomide: 20 mg per day, after an initial loading dose of 100 mg per day for three days only 3

From the Research

Treatment Approach for Rheumatoid Arthritis (RA)

The treatment for a new case of Rheumatoid Arthritis (RA) is often holistic, integrating medication, physical therapy, and lifestyle modifications 4. The main objective is to achieve remission or low disease activity by utilizing a "treat-to-target" approach that optimizes drug usage and dose adjustments based on clinical response and disease activity markers.

Disease-Modifying Antirheumatic Drugs (DMARDs)

• The primary RA treatment uses DMARDs that help to interrupt the inflammatory process 4.
• Methotrexate (MTX) is still considered the anchor drug among the disease-modifying antirheumatic agents and is widely accepted as the first-line treatment in the management of RA 5.
• Combination DMARD therapy may be used initially or in a step-up strategy after MTX monotherapy in patients with persistently active disease on monotherapy 5.

Treatment Algorithm

• Every patient suffering from active RA should be treated with DMARDs, but MTX initially remains the first choice treatment 6.
• Treatment should comply with the treat-to-target principle, with the therapeutic aim being remission if attainable or at least a low disease activity 6.
• A first evaluation of the response is due after 12 weeks, and if no improvement has been achieved, treatment should be continued with either a second DMARD strategy or an alternative with biological (bDMARD) or targeted synthetic (tsDMARD) DMARD 6.

Biological Therapies

• Biological therapies target inflammatory pathways and have shown promising results in managing RA symptoms 4.
• The use of biologics has to be considered in patients at risk for rapid radiographic progression 5.
• Switching to another mechanism of action may be the most successful approach if the initial DMARD treatment fails 7.

Treatment Guidelines

• Effective treatments include oral conventional synthetic DMARDs (e.g., methotrexate), injectable biologic DMARDs, and targeted synthetic DMARDs (oral) 8.
• Key recommendations are to start effective treatment immediately with DMARDs to reduce disability, use effective doses of methotrexate with folic acid as the initial treatment, and rapidly escalate treatment with various DMARDs if methotrexate alone is not effective in controlling RA 8.