What is the initial treatment for Rheumatoid Arthritis (RA)?

Initial Treatment for Rheumatoid Arthritis (RA)

Methotrexate (MTX) should be part of the first treatment strategy in patients with active RA and should be started as soon as the diagnosis of RA is made. 1

First-Line Treatment Approach

• Therapy with disease-modifying antirheumatic drugs (DMARDs) should be initiated immediately upon diagnosis of RA, as the disease will not remit spontaneously 1
• MTX is the preferred initial DMARD for most patients with newly diagnosed RA due to its favorable risk/benefit ratio, good safety profile, and low cost 1, 2
• The recommended starting dose of MTX is 15 mg/week orally, with escalation to 25-30 mg/week or the highest tolerable dose if needed 2
• If oral MTX is not effective enough, consider switching to subcutaneous administration which has higher bioavailability 2

For Patients with MTX Contraindications

• In cases of MTX contraindications or early intolerance, sulfasalazine or leflunomide should be considered as part of the first treatment strategy 1
• These alternative DMARDs have demonstrated efficacy but are generally considered less effective than MTX as initial therapy 1

Adjunctive Therapy

• Low-dose glucocorticoids (≤10 mg/day of prednisone or equivalent) should be considered as part of the initial treatment strategy in combination with DMARDs for up to 6 months 1
• Glucocorticoids should be tapered as rapidly as clinically feasible to minimize long-term adverse effects 1
• Short-term glucocorticoids (defined as <3 months treatment) may also be considered for disease flares 1

Treatment Target and Monitoring

• Treatment should aim at reaching a target of remission or low disease activity in every patient 1
• Monitoring should be frequent in active disease (every 1-3 months) 1
• If there is no improvement by at most 3 months after starting treatment or if the target has not been reached by 6 months, therapy should be adjusted 1

Combination Therapy Considerations

• In DMARD-naïve patients, DMARD monotherapy (particularly MTX) is generally preferred over combination DMARD therapy initially 1
• If the treatment target is not achieved with the first DMARD strategy:
  • In patients without poor prognostic factors: Consider changing to another conventional synthetic DMARD strategy 1
  • In patients with poor prognostic factors (RF/ACPA positivity, high disease activity, early joint damage): Consider adding a biologic DMARD 1

Common Pitfalls and Caveats

• Delayed initiation of DMARD therapy can lead to irreversible joint damage and disability 1, 3
• Patients often associate MTX with adverse events related to its high-dose use in cancer treatment; proper education about the much lower doses used in RA is essential 1, 4
• Inadequate dosing of MTX is a common mistake; doses should be optimized before concluding treatment failure 2, 5
• Folic acid supplementation should be provided with MTX to reduce side effects 3
• Nausea is more common when starting at higher MTX doses (15 mg vs. 7.5 mg), though efficacy outcomes may be similar with rapid dose escalation 5

Following these evidence-based recommendations will help achieve optimal outcomes in terms of controlling disease activity, preventing joint damage, and preserving function in patients with newly diagnosed RA.