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Rheumatoid arthritis

Description

An in-depth report on the causes, diagnosis, treatment, and prevention of rheumatoid arthritis.

Alternative Names

Arthritis - rheumatoid

Treatment

The treatment of rheumatoid arthritis involves medications and lifestyle changes.

General Guidelines for Drug Treatments

Many drugs are used for managing the pain and slowing the progression of rheumatoid arthritis, but none completely cure the disease. Some experts believe that no single drug will ever cure rheumatoid arthritis because of the many factors that affect the disease at various times. The goals of drug treatment for rheumatoid arthritis include:

• Reduce inflammation
• Prevent damage to the bones and ligaments of the joint
• Preserve movement
• To be as inexpensive and as free from side effects as possible over the long-term

Drug Categories Used for Rheumatoid Arthritis

The drug categories used for RA include:

• Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) are the least potent drugs used for RA. These drugs relieve pain by reducing inflammation, but do not contain steroids.
• Disease-Modifying Anti-Rheumatic Drugs (DMARDs) are the main drugs used for treating rheumatoid arthritis. They slow the progression of the disease. They are much more effective than NSAIDs but also have more side effects. Methotrexate (Rheumatrex, Trexall) is the most widely used of these drugs.
• Biologic Response Modifiers (also known as Biologic DMARDs) are often prescribed to patients who have failed to respond to DMARDs. They may be used alone or in combination with DMARDs such as methotrexate. They modify or block destructive immune factors such as tumor-necrosis factor (TNF). Current anti-TNF drugs include infliximab (Remicade), etanercept (Enbrel), and adalimumab (Humira). Other biologic response modifiers include the interleukin-1 antagonist anakinra (Kineret), the T-cell co-stimulation modulator abatacept (Orencia), and rituximab (Rituxan), which targets CD20-positive B cells.
• Corticosteroids , or steroids, are powerful anti-inflammatory drugs that are used to quickly reduce inflammation. These drugs include prednisone and prednisolone.
• Immunosuppressant drugs are used for disease that recurs or does not respond to other drugs. They inhibit the immune system and have potentially very serious side effects. These drugs include azathioprine (Imuran) and cyclophosphamide (Cytoxan)

Treatment Approaches

The question of how early and how aggressively to treat RA has been the subject of great debate. Current practice has moved towards treating the disease aggressively while it is in its early stages to help prevent it from reaching a more severe and chronic state.

Studies have found less joint damage in patients with early, aggressive treatment, particularly with the use of DMARDs and TNF modifiers. Research from 2006 showed promising results from early treatment with methotrexate in combination with either infliximab (Remicade) or adaliumumab (Humira). Other studies indicate that intensive early dosing of methotrexate may help slow progression of rheumatoid arthritis. Early combination therapy with DMARDs and corticosteroids is also showing good results. Some experts believe that with early aggressive therapy, remissions may be so successful that RA might even be considered potentially curable. There is also evidence that early use of DMARDs may help protect against heart problems, which can be major complications of RA.

It is not fully clear, however, which patients should receive such early aggressive treatment. Of all patients with RA, some will go into remission and remain in remission for the length of their lives even in the absence of treatment, while others will go on to develop active, sometimes severe RA. European researchers found that if the disease subsides within 3 months after diagnosis, patients tend to stay in remission. If disease persists beyond 3 months, it is likely to persist long-term. At this time, the evidence suggests that people who are most likely to develop severe disease have the following characteristics:

• Positive rheumatoid factor
• Antibodies to CCP
• Early erosive damage to joints
• Persistent inflammation despite steroids or NSAIDs

These indicators are not absolute, and further study is underway to better determine who is at greatest risk of disease progression, and how beneficial early aggressive therapy is among different patient populations. Nevertheless, new "early arthritis centers" are encouraging people with the earliest symptoms to seek help from arthritis specialists, with the hope of detecting and treating the disease before symptoms progress.

Layered or Step Approach

Given the recent evidence and the important questions still outstanding, a layered, "step-up" or "step-down" approach probably describes the manner in which therapies are administered in the majority of cases today. One or more drugs may be given for a period of time; depending on symptoms one or more may be added or dropped as needed.

Because there are so many potential combinations, it is not possible to list a typical regimen. Numerous variables affects which drugs may be prescribed at a given time, including the severity of disease, how well a particular drug has worked for an individual, patient preferences regarding pills or injections, side effects, and other factors.

Overall, however, doctors are increasingly using stronger medications first, based on studies showing that joint damage can be slowed or stopped with the early use of such drugs. Combinations of DMARDs (especially methotrexate) and biological drugs (TNF modifiers) are considered by far the most effective therapies. DMARDs combined with a corticosteroid such as prednisone are also showing good results.

• Review Date: 1/16/2007
• Reviewed By: Harvey Simon, MD, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital.

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