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]

Overview

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

References

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