What is the treatment for rheumatoid arthritis?

Treatment of Rheumatoid Arthritis

The optimal treatment for rheumatoid arthritis begins with methotrexate as first-line therapy, followed by combination DMARDs or biologics for inadequate response, with the goal of achieving low disease activity or remission through a treat-to-target approach. 1, 2, 3

Initial Treatment Approach

• Start methotrexate (MTX) as first-line therapy at 15-25 mg weekly (or maximum tolerated dose), as it is the most effective conventional disease-modifying antirheumatic drug (DMARD) 1, 3
• Consider switching to subcutaneous MTX administration if oral MTX provides inadequate response, as it has better bioavailability at higher doses 1, 4
• Add folic acid supplementation to reduce MTX-related side effects 3
• Evaluate disease activity using validated measures such as the Simplified Disease Activity Index (SDAI) or Clinical Disease Activity Index (CDAI) to guide treatment decisions 1

Management of Acute Flares

• For acute flares, low-dose glucocorticoids (≤10 mg/day prednisone or equivalent) can provide rapid symptom relief 2
• Use glucocorticoids at the lowest possible dose and for the shortest duration (less than 3 months) to minimize adverse effects 2
• For isolated joint involvement, consider intra-articular glucocorticoid injections for targeted relief 1, 2

Treatment Escalation for Inadequate Response

• If MTX monotherapy provides inadequate response after 3 months, consider the following options:

Option 1: Triple DMARD Therapy

• Add sulfasalazine (SSZ) and hydroxychloroquine (HCQ) to MTX for triple therapy 1, 2, 5
• This combination has shown superior efficacy compared to MTX alone or dual therapy with SSZ and HCQ 5

Option 2: Biologic DMARDs

• For patients with moderate to high disease activity despite optimized MTX, consider adding a biologic DMARD 1, 6
• TNF inhibitors (such as adalimumab) are commonly used first-line biologics in combination with MTX 7, 8
• For patients with inadequate response to TNF inhibitors, consider switching to a different class of biologic:
  • Abatacept (CTLA4-Ig)
  • Tocilizumab (anti-IL-6R)
  • Rituximab (anti-CD20) - particularly effective in seropositive patients 1, 9, 10

Monitoring and Treatment Goals

• Monitor disease activity every 1-3 months in active disease 1, 6
• The treatment target should be low disease activity or remission 2, 3
• Adjust therapy if target is not achieved within 3 months 1, 6
• Consider cautious de-escalation of therapy for patients in sustained remission (≥1 year), but be prepared to resume previous treatment if flares occur 1

Important Considerations and Pitfalls

• Screen for latent tuberculosis, hepatitis B, and other infections before starting biologic therapy 7, 9
• When switching biologics, consider using agents with different mechanisms of action rather than switching within the same class 1
• Monitor for potential adverse effects:
  • For MTX: liver function, blood counts, and pulmonary symptoms 4, 10
  • For biologics: increased risk of serious infections, including tuberculosis reactivation 7, 9
• Biomarker-guided therapy: Consider that seronegative patients with inadequate response to TNF inhibitors may respond better to abatacept or tocilizumab rather than rituximab 1