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. It is likely 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 affect the course of the disease.
• 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.

Treatment Approaches

The question of how early and how aggressively to treat RA has been the subject of great debate. Among 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.

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 in combination with methotrexate. Intensive early dosing of methotrexate may help slow progression of rheumatoid arthritis. Early combination therapy with DMARDs and corticosteroids is also showing good results.

Patients who have not been helped by one drug often benefit from a combination of drugs. However, over a longer period of time, it is not clear whether a drug combination approach offers many advantages over single drugs. It is also not certain which combination of drugs works best. Depending on your particular health condition, and how you respond to the drugs prescribed, your doctor may try various treatment strategies.

Current DMARD guidelines from the American College of Rheumatology recommend:

• Single DMARD. Methotrexate or leflunomide as initial therapy for most patients with RA
• Dual DMARD Therapy. Methotrexate plus hydroxychloroquine for patients with moderate-to-high disease activity
• Triple DMARD Therapy. Methotrexate plus hydroxychloroquine plus sulfasalazine for patients with poor prognostic features and moderate-to-high levels of disease activity.
• Anti-TNF DMARDs. For patients with early RA (less than 3 months), etanercept, infliximab,or adalimumab (along with methotrexate) should be reserved only for patients with high disease activity who have never received DMARDs. For longer duration RA, anti-TNF drugs are recommended for patients who have not been helped by methotrexate.
• Other Biologic DMARDs. Abatacept and rituximab should be reserved for patients with at least moderate disease activity and poor disease prognosis who were not helped by methotrexate and other nonbiologic DMARDs.

[For more specific information on these drugs, see Medications section of this report.]