What is the treatment for Rheumatoid arthritis?

Treatment for Rheumatoid Arthritis

Methotrexate (MTX) is the first-line disease-modifying antirheumatic drug (DMARD) for most patients with newly diagnosed rheumatoid arthritis, optimized to 20-25 mg weekly or maximum tolerated dose. 1, 2

Initial Treatment Approach

• Start MTX immediately upon diagnosis at 15mg weekly and titrate up to 20-25mg weekly or maximum tolerated dose to prevent joint damage and disability 1, 2
• Short-term low-dose glucocorticoids can be added to provide rapid symptomatic relief while waiting for DMARDs to take effect 1, 2
• For patients with contraindications to MTX, alternative conventional synthetic DMARDs include hydroxychloroquine, sulfasalazine, or leflunomide 1, 2
• NSAIDs like naproxen may be used for symptomatic relief but do not modify disease progression 3

Treatment Goals and Monitoring

• Aim for clinical remission (SDAI ≤3.3, CDAI ≤2.8) or at minimum low disease activity (SDAI ≤11, CDAI ≤10) 4, 1
• Monitor disease activity every 1-3 months during active disease using validated measures such as SDAI or CDAI 1, 5
• If no improvement is seen within 3 months or the target is not reached by 6 months, therapy should be adjusted 1, 2

Treatment Escalation for Inadequate Response

At 3-6 Months with Inadequate Response to MTX:

• For patients with moderate disease activity (SDAI >11 to ≤26 or CDAI >10 to ≤22), consider: 4, 1
  • Triple DMARD therapy by adding sulfasalazine and hydroxychloroquine to MTX
  • Switching to subcutaneous MTX for better bioavailability

At 6-12 Months with Inadequate Response:

• For patients with persistent moderate to high disease activity despite optimized conventional DMARDs, add: 4, 1, 2

  • Biologic DMARDs: TNF inhibitors (e.g., adalimumab), T-cell costimulation modulator (abatacept), IL-6 receptor antagonist (tocilizumab), or anti-CD20 antibody (rituximab)
  • Targeted synthetic DMARDs: JAK inhibitors

• The American College of Rheumatology recommends that if MTX monotherapy fails, consider triple DMARD therapy before biologics 1, 6

Management of Treatment Failure

• If the first biologic DMARD fails, switch to another biologic DMARD with a different mechanism of action 1, 2
• For patients who fail TNF inhibitor therapy (like adalimumab), consider switching to abatacept, tocilizumab, or rituximab 4, 2
• Tocilizumab has shown to be the most effective biologic as monotherapy when MTX cannot be used 7

Flare Management

• For isolated joint flares, consider intra-articular glucocorticoid injections 5, 2
• For systemic flares, short-term oral glucocorticoids may be used 1, 5
• Optimize current DMARD therapy by ensuring maximum tolerated doses 5

Important Considerations and Pitfalls

• Delaying DMARD initiation can lead to irreversible joint damage and worse long-term outcomes 1, 8
• Inadequate MTX dosing (not reaching 20-25mg weekly) or insufficient duration of treatment trial (less than 3 months) before concluding treatment failure 1
• Long-term glucocorticoid use beyond 1-2 years should be avoided due to risks of cataracts, osteoporosis, and cardiovascular disease 1, 2
• Patients starting biologic therapy should be screened for tuberculosis and hepatitis B/C 1, 9
• TNF inhibitors like adalimumab carry risks of serious infections and malignancy, requiring careful monitoring 9

Treatment Tapering

• For patients in sustained remission (≥1 year), consider cautious de-escalation of therapy, typically tapering biologics first, then reducing conventional DMARDs 1, 2
• Complete drug-free remission is achievable in only 15-25% of patients; most will require ongoing DMARD therapy 1, 2