What is the best practice for treating Rheumatoid Arthritis (RA)?

From the Guidelines

The best practice for treating rheumatoid arthritis (RA) involves initiating therapy with DMARDs as soon as the diagnosis is made, with the goal of reaching sustained remission or low disease activity (LDA) in every patient. This approach is supported by the 2019 update of the EULAR recommendations for the management of RA with synthetic and biological disease-modifying antirheumatic drugs 1. The guidelines emphasize the importance of starting DMARD therapy immediately, as the disease will not remit spontaneously.

Key aspects of RA management include:

• Starting therapy with DMARDs as soon as the diagnosis is made
• Aiming for a target of sustained remission or LDA in every patient
• Monitoring disease activity frequently (every 1-3 months) and adjusting therapy if there is no improvement by 3 months or if the target has not been reached by 6 months
• Considering alternative DMARDs, such as leflunomide or sulfasalazine, in patients with a contraindication to methotrexate (MTX) or early intolerance 1.

In terms of specific treatment strategies, the guidelines suggest that therapy 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. This may involve switching to or adding other conventional DMARDs or progressing to biologic DMARDs or targeted synthetic DMARDs. Regular monitoring and disease activity assessments are crucial to guide treatment decisions and ensure that patients receive the most effective therapy for their individual needs.

From the FDA Drug Label

Leflunomide is indicated in adults for the treatment of active rheumatoid arthritis (RA): to reduce signs and symptoms to inhibit structural damage as evidenced by X-ray erosions and joint space narrowing to improve physical function Aspirin, nonsteroidal anti-inflammatory agents and/or low dose corticosteroids may be continued during treatment with leflunomide The combined use of leflunomide with antimalarials, intramuscular or oral gold, D penicillamine, azathioprine, or methotrexate has not been adequately studied

The best practice when treating Rheumatoid Arthritis (RA) is to use leflunomide to reduce signs and symptoms, inhibit structural damage, and improve physical function.

• Treatment goals include reducing signs and symptoms, inhibiting structural damage, and improving physical function.
• Concomitant medications such as aspirin, nonsteroidal anti-inflammatory agents, and/or low dose corticosteroids may be continued during treatment with leflunomide.
• Combination therapy with other medications such as antimalarials, intramuscular or oral gold, D penicillamine, azathioprine, or methotrexate has not been adequately studied and should be used with caution 2.
• Rituximab may also be used in combination with 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 3.

From the Research

Best Practices for Treating RA

• Early aggressive therapy is recommended for patients suspected of having RA, including early referral to a rheumatologist and aggressive therapy with DMARDs, glucocorticoids, and biological agents 4.
• The use of DMARDs, such as methotrexate, hydroxychloroquine, sulfasalazine, and leflunomide, is considered first-line therapy for all newly diagnosed cases of RA 4, 5.
• Combination therapy with DMARDs, such as methotrexate and sulfasalazine, is a widely used therapeutic alternative and is associated with improved disease control and slower radiological progression 6.
• The goal of treatment should be to achieve low disease activity or remission, and treatment should be escalated rapidly if the initial therapy is not effective in controlling RA 5.
• Leflunomide-based triple therapy is non-inferior to sulfasalazine-based triple therapy in methotrexate-refractory RA patients, with a comparable safety profile 7.

Treatment Options

• DMARDs, such as methotrexate, hydroxychloroquine, sulfasalazine, and leflunomide, are effective in slowing clinical and radiographic progression of RA 4, 5.
• Biological-response modifiers, such as infliximab, etanercept, and adalimumab, are targeted agents that selectively inhibit specific molecules of the immune system and are effective in treating RA 4.
• Glucocorticoids and other antirheumatic drugs are also used to treat RA, and are effective in controlling pain, inflammation, and stiffness related to RA 4.

Treatment Guidelines

• The American Society of Health-System Pharmacists recommends the use of DMARDs, glucocorticoids, and biological agents in the treatment of RA 4.
• The Rheumatic Diseases Clinics of North America recommends starting effective treatment immediately with DMARDs to reduce disability, and rapidly escalating treatment with various DMARDs if methotrexate alone is not effective in controlling RA 5.