From the Guidelines
Rheumatoid arthritis (RA) treatment should start with methotrexate (MTX) as first-line therapy at 15-25mg weekly, often with folic acid supplementation to reduce side effects, and the goal of treatment should be to reach a target of sustained remission or low disease activity (LDA) in every patient. This approach is supported by the European League Against Rheumatism (EULAR) recommendations for the management of RA with synthetic and biological disease-modifying antirheumatic drugs (DMARDs) 1. The treatment strategy should be adjusted 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 1.
Key Principles of RA Treatment
- Therapy with DMARDs should be started as soon as the diagnosis of RA is made 1
- Treatment should be aimed at reaching a target of sustained remission or LDA in every patient 1
- Monitoring should be frequent in active disease (every 1–3 months) 1
- In patients with a contraindication to MTX (or early intolerance), leflunomide or sulfasalazine should be considered as part of the (first) treatment strategy 1
Treatment Options
- For acute flares, short-term prednisone (5-10mg daily for 2-4 weeks with tapering) can provide rapid symptom relief
- If methotrexate alone is insufficient after 3 months, combination therapy with other conventional DMARDs like hydroxychloroquine (200-400mg daily), sulfasalazine (2-3g daily), or leflunomide (10-20mg daily) is recommended
- For patients with inadequate response to conventional DMARDs, biologic agents such as TNF inhibitors (adalimumab, etanercept, infliximab), IL-6 inhibitors (tocilizumab), T-cell costimulation modulators (abatacept), or JAK inhibitors (tofacitinib, baricitinib) should be considered 1
Non-Pharmacological Approaches
- Physical therapy, occupational therapy, and regular low-impact exercise are essential components of comprehensive RA management
- Early aggressive treatment is crucial as it can prevent joint damage, maintain function, and potentially lead to remission in many patients
From the FDA Drug Label
1.1 Rheumatoid Arthritis (RA) ACTEMRA® (tocilizumab) is indicated for the treatment of adult patients with moderately to severely active rheumatoid arthritis who have had an inadequate response to one or more Disease-Modifying Anti-Rheumatic Drugs (DMARDs). 2.2 Recommended Dosage for Rheumatoid Arthritis ACTEMRA may be used as monotherapy or concomitantly with methotrexate or other non-biologic DMARDs as an intravenous infusion or as a subcutaneous injection
Treating RA: Tocilizumab (IV) is indicated for the treatment of adult patients with moderately to severely active rheumatoid arthritis who have had an inadequate response to one or more Disease-Modifying Anti-Rheumatic Drugs (DMARDs) 2. The recommended dosage for rheumatoid arthritis is as monotherapy or concomitantly with methotrexate or other non-biologic DMARDs as an intravenous infusion or as a subcutaneous injection 2.
- Key points:
- Tocilizumab can be used as monotherapy or with methotrexate or other non-biologic DMARDs.
- It is indicated for adult patients with moderately to severely active rheumatoid arthritis.
- Patients should have had an inadequate response to one or more DMARDs.
From the Research
Treatment Options for Rheumatoid Arthritis (RA)
- Rheumatoid arthritis is a common autoimmune, destructive, inflammatory arthritis in adults, and effective treatments include oral conventional synthetic disease-modifying antirheumatic drugs (DMARDs), injectable biologic DMARDs, and targeted synthetic DMARDs (oral) 3.
- The primary goal of treatment is to reduce disability, and key recommendations include starting effective treatment immediately with DMARDs, using effective doses of methotrexate with folic acid as the initial treatment, and rapidly escalating treatment with various DMARDs if methotrexate alone is not effective in controlling rheumatoid arthritis 3.
- DMARDs have been shown to be superior to placebo in controlled short-term clinical studies, and early and continuous use of DMARDs is necessary to slow joint damage and improve long-term outcomes 4.
Disease-Modifying Antirheumatic Drugs (DMARDs)
- Conventional DMARDs, such as methotrexate, are commonly used as the first line of treatment for RA, and they have been shown to be effective in reducing disease activity and slowing joint damage 4, 5.
- Biologic DMARDs, such as tumor necrosis factor-alpha (TNF-alpha) inhibitors, have also been shown to be effective in treating RA, particularly in patients who have not responded to conventional DMARDs 5, 6.
- Targeted synthetic DMARDs, such as tofacitinib, have also been developed and have shown promise in treating RA, particularly in patients who have not responded to conventional DMARDs 6.
Treatment Strategies
- A treat-to-target strategy, with a goal of low disease activity or remission, is recommended, and disease activity should be frequently monitored and treatment escalated as needed 3.
- Combination therapy with conventional and biologic DMARDs may be effective for treating seronegative patients with moderate to high RA activity 5.
- Methotrexate monotherapy is currently considered the best-practice model for treating RA, compared with combination therapy of methotrexate and/or other DMARDs 7.