What is the treatment for Rheumatoid Arthritis (RA) affecting the hands?

Treatment for Rheumatoid Arthritis Affecting the Hands

The treatment for rheumatoid arthritis affecting the hands should follow a structured approach beginning with methotrexate as first-line therapy, potentially combined with short-term glucocorticoids, and escalating to combination DMARDs or biologics if treatment targets are not achieved within 3-6 months. 1

Pharmacological Management

First-Line Therapy

• Methotrexate (MTX) is the cornerstone first-line treatment for RA affecting the hands, starting at 15mg weekly and optimizing to 20-25mg weekly as tolerated 1
• Short-term low or high-dose glucocorticoids can be combined with MTX initially to achieve rapid symptom control while waiting for DMARDs to take effect 1
• For patients with contraindications to MTX, alternatives include leflunomide, sulfasalazine, or hydroxychloroquine 1

Treatment Escalation

• If treatment target (remission or low disease activity) is not achieved within 3-6 months with optimal MTX dosing, therapy should be escalated 1
• For patients with moderate disease activity (SDAI >11 to ≤26 or CDAI >10 to ≤22), consider:
  • Adding sulfasalazine and hydroxychloroquine to MTX (triple therapy) 1, 2
  • Switching to subcutaneous MTX if oral administration was used 1
• For patients with high disease activity (SDAI >26 or CDAI >22) or poor prognostic factors (RF/ACPA positive, high disease activity, early joint damage):
  • Add a biologic DMARD, preferably a TNF inhibitor (adalimumab, etanercept) or abatacept 1
  • Alternative biologics include tocilizumab (IL-6 receptor antagonist) or rituximab (anti-CD20) 1, 3

Treatment Monitoring and Adjustment

• Assess treatment response every 1-3 months in active disease 3
• If no improvement is seen after 3 months, therapy should be adjusted 1, 3
• Any new treatment should be tried for at least 3-6 months to fully assess efficacy 1, 3

Non-Pharmacological Management for Hand RA

Hand Therapy

• Hand therapy exercises are recommended for patients with hand involvement to reduce pain and improve function 1
• Evaluation by an experienced hand therapist (e.g., certified hand therapist) is beneficial to guide specific exercise design and intensity 1

Splinting and Orthoses

• Splinting, orthoses, and/or compression are recommended for patients with hand/wrist involvement or deformity 1
• These interventions should be prescribed and fitted under the guidance of an experienced occupational therapist to ensure appropriate selection and fit 1

Joint Protection Techniques

• Joint protection techniques are recommended to reduce stress on affected joints and improve function 1
• These techniques help preserve joint integrity and reduce pain during daily activities 1

Assistive Devices and Adaptive Equipment

• Assistive devices are recommended to help maintain independence and function 1
• Adaptive equipment can be used to modify the environment and make daily tasks easier 1

Treatment Algorithm for RA Affecting the Hands

1. Initial Assessment

   • Confirm diagnosis of RA
   • Assess disease activity, prognostic factors, and comorbidities

2. Initial Treatment

   • Start MTX 15mg weekly, increase to 20-25mg as tolerated
   • Consider short-term glucocorticoids for rapid symptom control
   • Implement hand therapy exercises and joint protection techniques
   • Consider splinting/orthoses for symptom management

3. 3-6 Month Assessment

   • If treatment target achieved (remission or low disease activity): continue current therapy
   • If moderate disease activity persists: add sulfasalazine and hydroxychloroquine (triple therapy) or switch to subcutaneous MTX
   • If high disease activity or poor prognostic factors: add biologic DMARD (TNF inhibitor or abatacept)

4. Ongoing Management

   • Assess every 1-3 months until target achieved, then every 3-6 months
   • If treatment fails: switch to alternative biologic with different mechanism of action
   • Continue non-pharmacological interventions throughout treatment

Important Clinical Considerations

• Early aggressive treatment leads to better outcomes, including slower radiological progression and improved function 4, 5
• Triple therapy (MTX + sulfasalazine + hydroxychloroquine) has shown superior efficacy compared to MTX monotherapy, with 77% vs 33% of patients achieving 50% improvement 2
• Combination therapy is generally well-tolerated with no significant increase in adverse events compared to monotherapy 5
• NSAIDs like naproxen may provide symptomatic relief but do not modify disease progression and should be used for the shortest duration possible 6
• Biologic DMARDs should be used with caution in patients with history of serious infections, and screening for tuberculosis is required before initiating therapy 7