What is the initial treatment for a patient diagnosed with rheumatoid arthritis?

Initial Treatment for Rheumatoid Arthritis

Methotrexate should be the first-line treatment for patients diagnosed with rheumatoid arthritis, unless contraindicated, with consideration for short-term low-dose glucocorticoids as bridging therapy. 1, 2

First-Line Treatment Strategy

• Therapy with disease-modifying antirheumatic drugs (DMARDs) should be started as soon as the diagnosis of rheumatoid arthritis (RA) is made, ideally within 3 months of symptom onset 1
• Methotrexate is considered the anchor drug and should be part of the first treatment strategy in patients at risk of persistent disease 1
• Start methotrexate at an optimal dose of 15-25 mg weekly (as tolerated) with folic acid supplementation 2, 3
• Low-dose glucocorticoids (≤10 mg/day prednisone equivalent) should be considered as part of the initial treatment strategy for up to 6 months as bridging therapy until methotrexate becomes effective (typically 6-12 weeks) 1, 2
• Intra-articular glucocorticoid injections can be considered for relief of local symptoms of inflammation 1

Alternative First-Line Options

• For patients with contraindications to methotrexate (or early intolerance), sulfasalazine or leflunomide should be considered as part of the first treatment strategy 1
• In DMARD-naïve patients, conventional synthetic DMARD (csDMARD) monotherapy or combination therapy of csDMARDs can be used 1

Monitoring and Treatment Adjustment

• Disease activity should be monitored frequently (every 1-3 months) during active disease 1
• Monitoring should include tender and swollen joint counts, patient and physician global assessments, ESR and CRP, usually by applying a composite measure such as DAS28 1, 4
• If there is no improvement by at most 3 months after the start of treatment or the target has not been reached by 6 months, therapy should be adjusted 1

Treatment Escalation

• If the treatment target (remission or low disease activity) is not achieved with the first DMARD strategy, in the absence of poor prognostic factors, change to another csDMARD strategy should be considered 1
• When poor prognostic factors are present (high disease activity, positive rheumatoid factor/ACPA, early joint damage), addition of a biologic DMARD should be considered 1
• Triple therapy (methotrexate + sulfasalazine + hydroxychloroquine) is an effective alternative to biologic therapy for patients with inadequate response to methotrexate monotherapy 2

Non-Pharmacological Interventions

• Non-pharmacological interventions, such as dynamic exercises and occupational therapy, should be considered as adjuncts to drug treatment 1
• Smoking cessation, dental care, weight control, assessment of vaccination status, and management of comorbidities should be part of overall patient care 1
• Patient education about the disease, its outcome, and treatment is important 1

Common Pitfalls and Caveats

• Delaying DMARD therapy can lead to irreversible joint damage and disability; early treatment can prevent progression in up to 90% of patients 5
• NSAIDs should only be used at the minimum effective dose for the shortest time possible, after evaluation of gastrointestinal, renal, and cardiovascular risks 1
• Long-term use of glucocorticoids should be avoided due to cumulative side effects 1
• Patients must be in persistent low disease activity or remission for at least 6 months before considering any tapering of DMARDs 4
• Patients taking biologic agents should be tested for hepatitis B, hepatitis C, and tuberculosis before initiating therapy 6

The European League Against Rheumatism (EULAR) and American College of Rheumatology guidelines consistently emphasize early intervention with methotrexate as the cornerstone of RA treatment, with the goal of achieving remission or low disease activity as quickly as possible to prevent joint damage and disability 1, 7.