Rheumatoid arthritis medical therapy
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The mainstay of treatment of rheumatoid arthritis is pharmacotherapy. Early diagnosis of rheumatoid arthritis is helpful in treatment. Choice of treatment depends on various factors such as stage of disease, comorbid conditions, stage of therapy and presence of severe prognostic signs. There are two types of therapies- non-pharmacological therapy and pharmacological therapy. There are different drug regimen depending upon the stage of the disease. In active stage, combined therapy include disease-modifying antirheumatic drugs (DMARDs) are used along with the anti-inflammatory drugs. Therapy for resistant disease and flares is the addition of oral glucocorticoids. In case of the flare, add another DMARDs with methotrexate or replace with another DMARDs.
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.
- 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.
- The mainstay of treatment of rheumatoid arthritis is pharmacotherapy.
- Principles used for the treatment of rheumatoid arthritis are:
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 disease-modifying antirheumatic drugs (DMARDs) used are:
- Preferred regimen: Loading dose is 100 mg PO q24h for 3 days, the maintenance dose is 20 mg q24h (Contraindications in pregnancy)
- Preferred regimen: Initial dose: 500 mg PO q24h, the maintenance dose is 2 g PO once in 7days
- Preferred regimen: Initial dose: 400 mg PO q24h x 3months, the maintenance dose is 300 mg PO q24h (Special instructions an eye examination is required before starting the therapy)
- Preferred regimen:1000 mg IV 2 doses given 2 weeks apart, in combination with MTX
- Preferred regimen: 4mg/kg once every 4 weeks
- Preferred regimen: Initial dose 1mg/kg PO q24h for 6 to 8 weeks, the maintenance dose is reduction of dose 0.5mg/kg every week for 4 weeks
- Preferred regimen: 2.5mg/kg PO q12h for 8 weeks
- It is used in patients who are unresponsive to methotrexate
- Preferred regimen: 100 mg SC q24h
- This is used for slowing the progression of moderately to severely active RA
- Preferred regimen: dose is according to body weight such as <60kg -500mg, 60 to 100kg- 750mg and more than 100kg is 1000mg IV followed by same dose at 2 weeks, 4 weeks, and every 4 weeks afterwards
- This is used for moderately to severely active RA.
- The recommended dose of baricitinib is 2 mg once daily
- FDA approved for the treatment of adult patients with moderately to severely active rheumatoid arthritis who have had an inadequate response to one or more TNF antagonist therapies
DMARDs and TNF Inhibitors:
- This is the monoclonal antibody against TNF-α
- Preferred regimen: 3 mg/kg IV at weeks 0, 2, and 6 and then every 4-8 weeks, usually with MTX
- This is a bivalent p75–TNF receptor attached to the Fc portion of IgG human antibody
- Preferred regimen: 25 mg SC 2 times weekly or 50 mg SC once weekly, with or without concomitant MTX
- This is a human monoclonal antibody to TNF-α which inhibits TNF-α bioactivity
- Preferred regimen: 50 mg SC once every month
- This is a pegylated anti−TNF-α agent
- Preferred regimen: First dose of 400 mg SC followed by 2 doses of 400 mg SC at 2nd and 4th week, followed by 200 mg every other week
- This is the recombinant human IgG1 monoclonal antibody and it binds to TNF-α and blocks interaction with p55 and p75 cell-surface TNF receptors
- Preferred regimen: 40mg SC every other week
Different drug regimen depending upon the stage of 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.
Therapy for resistant disease and flares
- The patients who started on DMARDs and NSAIDs initially for 10 to 14 days, add oral glucocorticoids.
- Preferred regimen: Glucocorticoids 5 to 20mg/day PO depending on the severity of the disease.
- Intraarticular glucocorticoids are used in patient resistant to oral glucocorticoids.
- Preferred regimen: Intraarticular glucocorticoids 40 mg once for a large joint, 30 mg once for medium-sized joints, and 10 mg once for small joints.
- There is the severity of symptoms of ongoing treatment. We can add another DMARDs with methotrexate or replace with another DMARDs.
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