Rheumatoid arthritis medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Manpreet Kaur, MD [2]

Medical Therapy

Early diagnosis of rheumatoid arthritis is helpful in treatment. Choice of treatment depends on the following factors:

• Stage of disease (eg, mild/moderate/severe).
• Associated with other comorbid conditions.
• Stage of therapy (eg, initial versus subsequent therapy in patients resistant to treatment).
• Presence of severe prognostic signs.

Non-pharmacological treatment

• Heat or cold compresses are used to reduce the swelling, pain, and stiffness.
• Orthotics and splints
• Active and passive exercise helps in restoring range of motion.
• Patient education about taking healthy diet and taking proper rest.

Pharmacological treatment

• The mainstay of treatment of rheumatoid arthritis is pharmacotherapy.
• Principles used for the treatment of rheumatoid arthritis are:
  • Making an early diagnosis and taking early treatment is helpful.
  • Use of disease-modifying antirheumatic drugs early in the treatment.
  • Consult a specialist like a rheumatologist.
  • Use of anti-inflammatory drugs and glucocorticoids as an adjuvant.

Test to be done before starting the therapy

• CBC with differentials.
• ESR and CRP
• Serum creatinine
• Screen for Hepatitis B and Hepatitis C
• Test for latent tuberculosis
• Ophthalmological testing

Various therapy used depending upon the stage of disease:

• Active disease:
  • Combined therapy include disease-modifying antirheumatic drugs (DMARDs) are used along with the anti-inflammatory drugs.
  • The first line of the drug is Methotrexate along with anti-inflammatory drugs like NSAIDs and glucocorticoids.
  • Preferred regimen : Methotrexate 7.5 mg PO weekly for 4 weeks.
  • Followed by an increase in dose by 2.5mg PO or 5mg PO depending on the severity of disease and renal function.
  • Monitoring of renal function is done after 4 weeks.
  • Folic acid 1mg PO q24h or leucovorin weekly is usually added to MTX to avoid side effects.

Other disease-modifying antirheumatic drugs (DMARDs) used are:

• Leflunomide:
  • It is used in active disease, helps in improving physical activity.
  • Mechanism of action - it is a pyrimidine synthesis inhibitor that blocks autoimmune antibodies and reduces inflammation.
  • Leflunomide inhibits dihydroorotate dehydrogenase and has antiproliferative activity.
  • Contraindicated in pregnancy.
• Sulfasalazine:
  • Mechanism of action- it inhibits prostaglandin synthesis.
  • It is used in patients who are unresponsive to NSAIDs.
• Hydroxychloroquine:
  • It is used in chronic RA.
  • Before starting the drug, an eye examination is required.
• Rituximab:
  • This is used in combination with methotrexate (MTX).
  • It is used in treat patients with moderately to severely active RA who are unresponsive to therapy with 1 or more tumor necrosis factor (TNF) antagonists.
  • Regimen includes 1000 mg IV 2 doses given 2 weeks apart, in combination with MTX.
• Tocilizumab:
  • Mechanism of action- IL-6 receptor inhibitor.
  • It is used in moderate to severe cases who are unresponsive to tumor necrosis factor (TNF) antagonists.
  • Dose is 4mg/kg once every 4 weeks.
• Sarilumab:
  • This is a monoclonal antibody which is bound to IL6 receptors.
  • Used as monotherapy and in combination with other DMARDs.
• Azathioprine:
  • This is used in the cases when there are comorbidities associated with RA.
• Cyclosporins:
  • It is used in patients who are unresponsive to methotrexate.
• Anakinra:
  • It is an interleukin (IL)-1 receptor antagonist (IL-1Ra).
  • Preferred dose: 100 mg/day SC.
  • This is used for slowing the progression of structural damage of moderately to severely active RA that has failed treatment with 1 or more DMARDs.