What is the step-by-step approach for treating rheumatoid arthritis in India?

Step-by-Step Treatment of Rheumatoid Arthritis in India

The treatment of rheumatoid arthritis (RA) in India should follow a structured approach starting with methotrexate as first-line therapy, progressing to combination DMARDs, and then to biologics for refractory cases, with the goal of achieving low disease activity or remission to prevent joint damage and disability. 1

Initial Diagnosis and First-Line Treatment

• Start methotrexate (MTX) as the first-line disease-modifying antirheumatic drug (DMARD) at 15-25 mg weekly (as tolerated) for all newly diagnosed RA patients 2, 1
• Add short-term low-dose glucocorticoids (prednisone) to rapidly control symptoms while waiting for MTX to take effect 1
• For patients with contraindications to MTX, consider alternative conventional DMARDs like hydroxychloroquine, sulfasalazine, or leflunomide 1
• Monitor disease activity using validated measures such as Simplified Disease Activity Index (SDAI) or Clinical Disease Activity Index (CDAI) every 1-3 months 3
• Optimize MTX dose to 20-25 mg weekly or maximum tolerated dose before concluding treatment failure 1

Treatment Escalation (3-6 Months)

• If inadequate response to optimized MTX at 3 months (SDAI >11 or CDAI >10), consider treatment escalation 2
• For moderate disease activity (SDAI >11 to ≤26 or CDAI >10 to ≤22):
  • Add sulfasalazine and hydroxychloroquine to MTX (triple DMARD therapy) 2, 4
  • OR switch to subcutaneous MTX if oral administration shows poor response 2
• For high disease activity (SDAI >26 or CDAI >22):
  • Consider adding a biologic agent (TNF inhibitor or abatacept) 2
• Intra-articular glucocorticoid injections may be used for persistent inflammation in isolated joints 2

Treatment Approach at 6-12 Months

• If target of low disease activity (SDAI ≤11 or CDAI ≤10) is not achieved:
  • For patients on MTX monotherapy: Add sulfasalazine + hydroxychloroquine OR add/switch to a biologic agent 2
  • For patients already on MTX plus a biologic: Switch to an alternative biologic agent 2
• Common biologics available in India include TNF inhibitors (adalimumab, etanercept), IL-6 receptor antagonist (tocilizumab), T-cell costimulation modulator (abatacept), and anti-CD20 antibody (rituximab) 5, 1
• In the Indian context, methotrexate is the most commonly prescribed DMARD (100%), followed by hydroxychloroquine (23.3%), with biologics like adalimumab used less frequently (0.7%) due to cost considerations 5

Beyond 12 Months of Treatment

• For patients with persistent moderate to high disease activity despite treatment:
  • Increase MTX to maximum tolerated dose (20-25 mg/week) 2
  • Consider switching to subcutaneous MTX for better bioavailability 2
  • For patients on DMARD-only therapy: Initiate triple DMARD therapy 2
  • For patients on a biologic agent: Switch to an alternative biologic with a different mechanism of action 2
• Any new treatment should be tried for at least 3-6 months to fully assess efficacy 2
• Biomarker-guided treatment selection:
  • Presence of rheumatoid factor, anti-citrullinated protein antibodies, or increased serum IgG predicts better response to rituximab 2
  • Consider abatacept or tocilizumab for seronegative patients with inadequate response to TNF inhibitors 2

Monitoring and Treatment Targets

• Assess disease activity every 1-3 months in active disease 3
• Clinical response to biologics like tocilizumab typically begins within 4-6 weeks, but maximal efficacy may not be seen until 24 weeks 3
• Target should be remission (SDAI ≤3.3 or CDAI ≤2.8) or at least low disease activity (SDAI ≤11 or CDAI ≤10) 2
• If no improvement after 3 months of any therapy, treatment should be adjusted 3
• If target is not achieved by 6 months, consider changing therapy 2

Long-term Management and De-escalation

• For patients who achieve remission:
  • Continue current DMARD regimen 2
  • Taper and discontinue prednisone 2
  • If sustained remission for ≥1 year, consider cautious de-escalation of therapy (≤1 trial) 2, 1
• Approximately 15-25% of patients may achieve sustained drug-free remission 1

Common Pitfalls to Avoid in RA Management

• Delaying DMARD initiation, which can lead to irreversible joint damage 1
• Inadequate MTX dosing or insufficient duration before concluding treatment failure 1
• Long-term glucocorticoid use without monitoring for adverse effects 1
• Failure to adjust therapy when treatment targets are not met 1
• Overlooking screening for tuberculosis and hepatitis B/C before starting biologic therapy, especially important in the Indian context 1