What are the management options for Rheumatoid Arthritis (RA)?

From the Guidelines

Rheumatoid arthritis management should start with methotrexate (MTX) plus short-term glucocorticoids (GCs), aiming for >50% improvement within 3 months and target attainment within 6 months, as recommended by the most recent EULAR guidelines 1.

Key Principles of Management

The management of rheumatoid arthritis (RA) involves a comprehensive approach that includes medications, lifestyle modifications, and regular monitoring. The primary goal is to achieve remission or low disease activity, which can prevent joint damage and improve quality of life.

• Treatment should begin with disease-modifying antirheumatic drugs (DMARDs), with methotrexate (MTX) being the first-line option at a dose of 7.5-25 mg weekly, often with folic acid supplementation to reduce side effects.
• For acute symptom control, NSAIDs like naproxen (500 mg twice daily) or ibuprofen (400-800 mg three times daily) can be used, while low-dose corticosteroids such as prednisone (5-10 mg daily) help bridge until DMARDs take effect.
• In patients with inadequate response to methotrexate after 3-6 months, combination therapy with other conventional DMARDs (hydroxychloroquine 200-400 mg daily, sulfasalazine 2-3 g daily, or leflunomide 20 mg daily) or progression to biologics like TNF inhibitors (adalimumab, etanercept) or JAK inhibitors (tofacitinib, baricitinib) is recommended, as per the updated EULAR recommendations 1.

Non-Pharmacological Approaches

Regular physical therapy, gentle exercise, and joint protection techniques are essential non-pharmacological approaches that should be integrated into the management plan.

• Disease activity should be monitored every 1-3 months initially using standardized measures, with the goal of achieving remission or low disease activity.
• The treat-to-target approach, which involves adjusting treatment until the target of remission or low disease activity is achieved, is recommended by the EULAR guidelines 1.

Treatment Strategies

The choice of treatment strategy depends on the presence of poor prognostic factors, such as autoantibodies, high disease activity, early erosions, or failure of two conventional synthetic DMARDs.

• With poor prognostic factors, any biological DMARD or JAK inhibitor should be added to the conventional synthetic DMARD, as recommended by the EULAR guidelines 1.
• If this fails, any other biological DMARD (from another or the same class) or targeted synthetic DMARD is recommended.
• On sustained remission, DMARDs may be tapered, but not stopped, to maintain disease control and prevent flare-ups, as suggested by the EULAR guidelines 1.

From the FDA Drug Label

Rheumatoid Arthritis including Polyarticular-Course Juvenile Rheumatoid Arthritis: Methotrexate is indicated in the management of selected adults with severe, active rheumatoid arthritis (ACR criteria), or children with active polyarticular-course juvenile rheumatoid arthritis, who have had an insufficient therapeutic response to, or are intolerant of, an adequate trial of first-line therapy including full dose non- steroidal anti-inflammatory agents (NSAIDs). Adults with Rheumatoid Arthritis (RA): with another prescription medicine called methotrexate, to reduce the signs and symptoms of moderate to severe active RA in adults, after treatment with at least one other medicine called a Tumor Necrosis Factor (TNF) antagonist has been used and did not work well

Rheumatoid Arthritis Management: Methotrexate is indicated for the management of severe, active rheumatoid arthritis in adults who have had an insufficient response to first-line therapy, including NSAIDs. Adalimumab can be used in combination with methotrexate to reduce the signs and symptoms of moderate to severe active RA in adults who have not responded to TNF antagonist therapy. Rituximab can also be used in combination with methotrexate to treat moderate to severe active RA in adults.

• Key points:
  • Methotrexate is used for severe, active rheumatoid arthritis
  • Adalimumab and rituximab can be used in combination with methotrexate for moderate to severe active RA
  • These medications are used after insufficient response to first-line therapy or TNF antagonist therapy 2, 3, 4

From the Research

Rheumatoid Arthritis Management

• Rheumatoid arthritis is the most common autoimmune, destructive, inflammatory arthritis in adults, and effective treatments include oral conventional synthetic disease-modifying antirheumatic drugs (DMARDs; eg, methotrexate), injectable biologic DMARDs, and targeted synthetic DMARDs (oral) 5.
• Key recommendations for managing rheumatoid arthritis include starting effective treatment immediately with DMARDs to reduce disability, using effective doses of methotrexate (oral or subcutaneous) with folic acid as the initial treatment, and rapidly escalating treatment with various DMARDs if methotrexate alone is not effective in controlling rheumatoid arthritis 5.
• Folic acid and folinic acid supplementation during methotrexate therapy can reduce the incidence of gastrointestinal side effects, hepatic dysfunction, and patient withdrawal from methotrexate treatment 6, 7.
• Folate supplementation can also promote compliance to methotrexate and reduce the risk of elevated transaminase and gastrointestinal side effects 6, 7.
• The effect of folate supplementation on methotrexate efficacy is still unclear, but most studies suggest that it does not significantly reduce the efficacy of methotrexate 6, 7, 8.
• Current guidelines for managing rheumatoid arthritis recommend regular assessments, targeting remission or low disease activity, and starting disease-modifying drugs (DMARDs) as soon as possible, with methotrexate being the recommended initial treatment 9.
• Biologics are recommended for patients with persistently active disease who have already received methotrexate, and most guidelines suggest tapering biologics when patients achieve sustained good responses 9.