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{{Rheumatoid arthritis}}
{{Rheumatoid arthritis}}
{{CMG}}; {{AE}} {{AN}}
{{CMG}}; {{AE}} {{MKK}}


==Overview==
==Overview==
There is no known cure for rheumatoid arthritis. However, many different types of treatment can be used to alleviate symptoms and/or to modify the disease process.
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 drug|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]].


==Medical Therapy==
==Medical Therapy==
The goal of treatment in this chronic disease must be two-fold:
The mainstay of treatment of [[rheumatoid arthritis]] is pharmacotherapy.
*To alleviate the suffering of the patient here and now, and
Early diagnosis of [[rheumatoid arthritis]] is helpful in treatment.
*To prevent the future destruction of the joints and resulting handicap if the disease is left unchecked.


These two goals may not always coincide: while pain relievers may achieve the first goal, they do not have any impact on the long-term consequences. For these reasons, most authorities believe that RA should be treated, in the vast majority of patients, by at least one specific anti-rheumatic medication, also named DMARD (see below), to which other medications and non-medical interventions can be added as needed.
Choice of treatment depends on the following factors:
*[[Cortisone]] therapy has offered relief to many patients in the past, but its long-term effects have been deemed undesirable.<ref>[http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1520676 [[NIH]]: Results of Long-Continued Cortisone Administration in Rheumatoid Arthritis]</ref>. However, cortisone injections can be valuable adjuncts to a long-term treatment plan, and using low dosages of daily cortisone (e.g., prednisone or prednisolone, 5-7.5 mg daily) can also have an important benefit if added to a proper specific anti-rheumatic treatment.
*Stage of [[disease]] (eg, mild/moderate/severe).
*[[Pharmacology|Pharmacological]] treatment of RA can be divided into [[disease-modifying antirheumatic drug]]s (DMARDs), [[anti-inflammatory]] agents and [[analgesic]]s.<ref>{{cite journal | author = O'Dell J | title = Therapeutic strategies for rheumatoid arthritis. | journal = N Engl J Med | volume = 350 | issue = 25 | pages = 2591-602 | year = 2004 | id = PMID 15201416}}</ref><ref>{{cite journal | author = Hasler P | title = Biological therapies directed against cells in autoimmune disease. | journal = Springer Semin Immunopathol | volume = 27 | issue = 4 | pages = 443-56 | year = 2006 | month=Jun | id = PMID 16738955}}</ref>
*Associated with other [[comorbid]] conditions.
*DMARDs have been found to produce durable remissions and delay or halt disease progression.
*Stage of [[therapy]] (eg, initial versus subsequent therapy in patients resistant to treatment).
*In particular they prevent bone and joint damage from occurring secondary to the uncontrolled inflammation.  This is important as such damage is usually irreversible.  
*Presence of severe [[prognostic]] signs.
*[[Anti-inflammatory drugs]] and [[analgesic]]s improve pain and [[joint stiffness]] but do not prevent joint damage or slow the disease progression. There is an increasing recognition amongst rheumatologists that permanent damage to the joints occurs at a very early stage in the disease.  
'''Non-pharmacological treatment'''
*In the past the strategy used was to start with just an anti-inflammatory drug, and assess progression clinically and using X-rays.  If there was evidence that joint damage was starting to occur then a more potent DMARD would be prescribed.  
*Heat or [[cold]] compresses are used to reduce the [[swelling]], [[pain]], and [[stiffness]].  
*Tools such as ultrasound and MRI are more sensitive methods of imaging the joints and have demonstrated that joint damage occurs much earlier and in more patients than was previously thought. Patients with normal X-rays will often have erosions detectable by ultrasound that X ray could not demonstrate.
*[[Orthotics]] and splints.
*There may be other reasons why starting DMARDs early is beneficial as well as prevention of structural joint damage.  In the early stage of the disease, the joints are increasingly infiltrated by cells of the immune system that signal to one another and are thought to set up self-perpetuating chronic inflammation.  
*Active and passive [[exercise]] helps in restoring range of motion.
*Interrupting this process as early as possible with an effective DMARD (such as methotrexate) appears to improve the outcome from the RA for years afterwards.  Delaying therapy for as little as a few months after the onset of symptoms can result in worse outcomes in the long term. *There is therefore considerable interest in establishing the most effective therapy in patients with early arthritis, when they are most responsive to therapy and have the most to gain.<ref>{{cite journal | author = Vital E, Emery P | title = Advances in the treatment of early rheumatoid arthritis. | journal = Am Fam Physician | volume = 72 | issue = 6 | pages = 1002, 1004 | year = 2005 | month=Sep 15 | id = PMID 16190499 | url=http://www.aafp.org/afp/20050915/editorials.html}}</ref>
*Patient [[education]] about taking healthy [[diet]] and taking proper rest.
*Treatment also includes rest and physical activity. Regular exercise is important for maintaining joint mobility and making the joint muscles stronger. Swimming is especially good, as it allows for exercise with a minimum of stress on the joints.
'''Pharmacological treatment'''
*Heat and cold applications are modalities that can ease symptoms before and after exercise. Pain in the joints is sometimes alleviated by oral [[acetaminophen]] (paracetamol). Other areas of the body, such as the eyes and lining of the heart, are treated individually.  However, there is no diet that has been shown to alleviate rheumatoid arthritis, although fish oil may have anti-inflammatory effects.
*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


===Disease modifying anti-rheumatic drugs (DMARDs)===
'''Various disease-modifying antirheumatic drugs (DMARDs) used are''':
*The term Disease Modifying Anti-Rheumatic Agent was originally introduced to indicate a drug that reduced evidence of processes thought to underly the disease, such as a raised [[erythrocyte sedimentation rate]], reduced [[hemoglobin]] level, raised [[rheumatoid factor]] level and more recently, raised [[C-reactive protein]] level.
*More recently, the term has been used to indicate a drug that reduces the rate of damage to [[bone]] and [[cartilage]].
*DMARDs can be further subdivided into traditional small molecular mass drugs synthesized chemically and newer 'biological' agents produced through genetic engineering.  Traditional small molecular mass drugs:
**[[Azathioprine]]
**[[Cyclosporin]] (cyclosporine A)
**[[D penicillamine]]
**[[Gold salts]]
**[[Hydroxychloroquine]]
**[[Leflunomide]]
**[[Methotrexate]] (MTX)
**[[Minocycline]]
**[[Sulfasalazine]] (SSZ)
*The most important and most common adverse events relate to [[liver]] and [[bone marrow]] toxicity ([[methotrexate]], [[sulfasalazine]], [[leflunomide]], [[azathioprine]], gold compounds, [[D-penicillamine]]), renal toxicity ([[cyclosporine]] A, parenteral gold salts, [[D penicillamine]]), [[pneumonitis]] ([[methotrexate]]), allergic [[skin]] reactions (gold compounds, [[sulphasalazine]]), autoimmunity ([[D penicillamine]], [[sulphasalazine]], [[minocycline]]) and infections ([[azathioprine]], [[cyclosporine A]]).
*[[Hydroxychloroquine]] may cause ocular toxicity, although this is rare, and because [[hydroxychloroquine]] does not affect the [[bone marrow]]or [[liver]] it is often considered to be the DMARD with the least toxicity.  Unfortunately [[hydroxychloroquine]] is not very potent, and for most patients [[hydroxychloroquine]] alone is insufficient to control symptoms.
*Many rheumatologists consider [[methotrexate]] to be the most important and useful DMARD, largely because of lower rates of stopping the drug through toxicity.  Nevertheless, [[methotrexate]] is often considered by patients and even other doctors as a very "toxic" drug.  This reputation is not entirely justified, and at times can result in patients being denied the most effective treatment for their arthritis. *Although [[methotrexate]] does indeed have the potential to suppress the [[bone marrow]] or cause [[hepatitis]], these effects can be monitored using regular blood tests, and the drug withdrawn at an early stage if the tests are abnormal, before any serious harm is done (typically the blood tests return to normal after stopping the drug).
*In clinical trials in which patients with RA were treated with one of a range of different DMARDs, patients who were prescribed [[methotrexate]] were those who stayed on their medication the longest (the others stopped theirs because of either side-effects or failure of the drug to control the arthritis).
*Lastly, [[methotrexate]] is often preferred by rheumatologists because if it does not control arthritis on its own then it works well in combination with many other drugs, especially the biological agents.  Other DMARDs may not be as effective or safe in combination with biological agents.


====Biological agents====
1)[[Leflunomide]]:
Biological agents ([[biologics]] include:
*Preferred regimen: Loading dose is 100 mg PO q24h for 3 days, the maintenance dose is 20 mg  q24h '''(Contraindications in pregnancy)'''   
*Tumor necrosis factor alpha (TNFα) blockers - [[etanercept]] (Enbrel), [[infliximab]] (Remicade), [[adalimumab]] (Humira), [[golimumab]] (Simponi)
2)[[Sulfasalazine]]:
*[[Interleukin 1]] blockers - [[anakinra]]
*Preferred regimen: Initial dose: 500 mg PO q24h, the maintenance dose is 2 g PO once in 7days 
*[[Monoclonal antibody|Monoclonal antibodies]] against [[B cell]]s - [[rituximab]] (Rituxan)<ref>{{cite journal | author = Edwards J, Szczepanski L, Szechinski J, Filipowicz-Sosnowska A, Emery P, Close D, Stevens R, Shaw T | title = Efficacy of B-cell-targeted therapy with rituximab in patients with rheumatoid arthritis. | journal = N Engl J Med | volume = 350 | issue = 25 | pages = 2572-81 | year = 2004 | id = PMID 15201414}}</ref>
3)[[Hydroxychloroquine]]:
*T cell activation blocker [[abatacept]] (Orencia)
*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)'''
4)[[Rituximab]]:
*Preferred regimen:1000 mg IV 2 doses given 2 weeks apart, in combination with [[Methotrexate|MTX]]
5)[[Tocilizumab]]:
*Preferred regimen: 4mg/kg once every 4 weeks
6)[[Azathioprine]]:
* 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
7) [[Cyclosporine|Cyclosporin]]:
*Preferred regimen: 2.5mg/kg  PO q12h  for 8 weeks
*It is used in patients who are unresponsive to [[methotrexate]]
8) [[Anakinra]]
*Preferred regimen: 100 mg SC q24h
*This is used for slowing the progression of moderately to severely active [[Rheumatoid arthritis|RA]]
9) [[Abatacept]]:
*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.
10) [[Baricitinib]]:
*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<br>


===Anti-inflammatory agents and analgesics===
'''DMARDs and TNF Inhibitors:'''
Anti-inflammatory agents include:
*[[Glucocorticoids]]: [[prednisone]], [[meprednisone]]
*[[Non-steroidal anti-inflammatory drug]] (NSAIDs, most also act as analgesics): [[ibuprofen]] (sdvil, motrin), [[diclofenac]] (cataflam, voltaren), [[naproxen]] (naprosync, aleve, anaprox), [[piroxicam]] (feldene), [[Celecoxib]] (celebrex)


Analgesics include:
1)[[Infliximab]]:
*[[Acetaminophen]] (Tylenol, Paracetamol outside US)
*This is the [[Monoclonal antibody|monoclonal]] [[antibody]] against TNF-α
*[[Opiates]]: [[Tramadol]] (ultram)
* Preferred regimen: 3 mg/kg IV at weeks 0, 2, and 6 and then every 4-8 weeks, usually with [[MTX]]
*[[Diproqualone]]
2)[[Etanercept]]:
*[[Lidocaine]] topical
*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
3)[[Golimumab]]:
*This is a human monoclonal antibody to TNF-α which inhibits TNF-α bioactivity
*Preferred regimen: 50 mg SC once every month
4)[[Certolizumab]]:
*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
5)[[Adalimumab]]:
*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. No clear benefit of 80 mg every other week<ref name="pmid12379628">{{cite journal| author=Rau R| title=Adalimumab (a fully human anti-tumour necrosis factor alpha monoclonal antibody) in the treatment of active rheumatoid arthritis: the initial results of five trials. | journal=Ann Rheum Dis | year= 2002 | volume= 61 Suppl 2 | issue= Suppl 2 | pages= ii70-3 | pmid=12379628 | doi=10.1136/ard.61.suppl_2.ii70 | pmc=1766697 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12379628  }} </ref>.


The [[Prosorba column]] blood filtering device was approved by the FDA for treatment of RA in 1999 <ref> Fresenius HemoCare, Inc., "New Hope for Rheumatoid Arthritis Patients," press release, September 17, 1999.</ref> However, in most patients the results have been very modest.
'''Different drug regimen depending upon the stage of disease''':


Historic treatments for RA have also included: [[RICE]], [[acupuncture]], apple diet, [[nutmeg]], some light exercise every now and then, [[nettle]]s, [[bee]] venom, [[copper]] bracelets, [[rhubarb]] diet, rest, extractions of teeth, [[fasting]], honey, [[vitamin]]s, [[insulin]], magnets, and [[electroconvulsive therapy]] (ECT).<ref>[http://www.pubmedcentral.nih.gov/picrender.fcgi?artid=1639217&blobtype=pdf [[NIH]]: History of the treatment of rheumatoid arthritis]</ref>. Most of these have either had no effect at all, or their effects have been modest and transient in some individual patients, while not being generalizable.
'''Active disease''':<ref name="pmid18635256">{{cite journal |vauthors=Emery P, Breedveld FC, Hall S, Durez P, Chang DJ, Robertson D, Singh A, Pedersen RD, Koenig AS, Freundlich B |title=Comparison of methotrexate monotherapy with a combination of methotrexate and etanercept in active, early, moderate to severe rheumatoid arthritis (COMET): a randomised, double-blind, parallel treatment trial |journal=Lancet |volume=372 |issue=9636 |pages=375–82 |date=August 2008 |pmid=18635256 |doi=10.1016/S0140-6736(08)61000-4 |url=}}</ref><ref name="pmid29073913">{{cite journal |vauthors=Darzi A, Harfouche M, Arayssi T, Alemadi S, Alnaqbi KA, Badsha H, Al Balushi F, Elzorkany B, Halabi H, Hamoudeh M, Hazer W, Masri B, Omair MA, Uthman I, Ziade N, Singh JA, Christiansen R, Tugwell P, Schünemann HJ, Akl EA |title=Correction to: Adaptation of the 2015 American College of Rheumatology treatment guideline for rheumatoid arthritis for the Eastern Mediterranean Region: an exemplar of the GRADE Adolopment |journal=Health Qual Life Outcomes |volume=15 |issue=1 |pages=214 |date=October 2017 |pmid=29073913 |pmc=5658904 |doi=10.1186/s12955-017-0791-9 |url=}}</ref>
*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|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.<ref name="pmid16258899">{{cite journal |vauthors=Goekoop-Ruiterman YP, de Vries-Bouwstra JK, Allaart CF, van Zeben D, Kerstens PJ, Hazes JM, Zwinderman AH, Ronday HK, Han KH, Westedt ML, Gerards AH, van Groenendael JH, Lems WF, van Krugten MV, Breedveld FC, Dijkmans BA |title=Clinical and radiographic outcomes of four different treatment strategies in patients with early rheumatoid arthritis (the BeSt study): a randomized, controlled trial |journal=Arthritis Rheum. |volume=52 |issue=11 |pages=3381–90 |date=November 2005 |pmid=16258899 |doi=10.1002/art.21405 |url=}}</ref><ref name="pmid18662933">{{cite journal |vauthors=van der Kooij SM, Goekoop-Ruiterman YP, de Vries-Bouwstra JK, Güler-Yüksel M, Zwinderman AH, Kerstens PJ, van der Lubbe PA, de Beus WM, Grillet BA, Ronday HK, Huizinga TW, Breedveld FC, Dijkmans BA, Allaart CF |title=Drug-free remission, functioning and radiographic damage after 4 years of response-driven treatment in patients with recent-onset rheumatoid arthritis |journal=Ann. Rheum. Dis. |volume=68 |issue=6 |pages=914–21 |date=June 2009 |pmid=18662933 |doi=10.1136/ard.2008.092254 |url=}}</ref>
*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.<ref name="pmid29129326">{{cite journal |vauthors=Xu C, Peng H, Li R, Chai W, Li X, Fu J, Liu K, Yu B, Jia C, Chen J |title=Risk factors and clinical characteristics of deep knee infection in patients with intra-articular injections: A matched retrospective cohort analysis |journal=Semin. Arthritis Rheum. |volume= |issue= |pages= |date=October 2017 |pmid=29129326 |doi=10.1016/j.semarthrit.2017.10.013 |url=}}</ref>
'''Flares'''
*There is the severity of symptoms of ongoing treatment. We can add another DMARDs with methotrexate or replace with another DMARDs.


==References==
==References==

Latest revision as of 13:35, 31 March 2024

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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

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.

Medical Therapy

The mainstay of treatment of rheumatoid arthritis is pharmacotherapy. 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

Pharmacological treatment

Test to be done before starting the therapy

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

1)Leflunomide:

  • Preferred regimen: Loading dose is 100 mg PO q24h for 3 days, the maintenance dose is 20 mg q24h (Contraindications in pregnancy)

2)Sulfasalazine:

  • Preferred regimen: Initial dose: 500 mg PO q24h, the maintenance dose is 2 g PO once in 7days

3)Hydroxychloroquine:

  • 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)

4)Rituximab:

  • Preferred regimen:1000 mg IV 2 doses given 2 weeks apart, in combination with MTX

5)Tocilizumab:

  • Preferred regimen: 4mg/kg once every 4 weeks

6)Azathioprine:

  • 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

7) Cyclosporin:

  • Preferred regimen: 2.5mg/kg PO q12h for 8 weeks
  • It is used in patients who are unresponsive to methotrexate

8) Anakinra

  • Preferred regimen: 100 mg SC q24h
  • This is used for slowing the progression of moderately to severely active RA

9) Abatacept:

  • 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.

10) Baricitinib:

  • 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:

1)Infliximab:

  • 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

2)Etanercept:

  • 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

3)Golimumab:

  • This is a human monoclonal antibody to TNF-α which inhibits TNF-α bioactivity
  • Preferred regimen: 50 mg SC once every month

4)Certolizumab:

  • 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

5)Adalimumab:

  • 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. No clear benefit of 80 mg every other week[1].

Different drug regimen depending upon the stage of disease:

Active disease:[2][3]

  • 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.[4][5]
  • 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.[6]

Flares

  • There is the severity of symptoms of ongoing treatment. We can add another DMARDs with methotrexate or replace with another DMARDs.

References

  1. ↑ Rau R (2002). "Adalimumab (a fully human anti-tumour necrosis factor alpha monoclonal antibody) in the treatment of active rheumatoid arthritis: the initial results of five trials". Ann Rheum Dis. 61 Suppl 2 (Suppl 2): ii70–3. doi:10.1136/ard.61.suppl_2.ii70. PMC 1766697. PMID 12379628.
  2. ↑ Emery P, Breedveld FC, Hall S, Durez P, Chang DJ, Robertson D, Singh A, Pedersen RD, Koenig AS, Freundlich B (August 2008). "Comparison of methotrexate monotherapy with a combination of methotrexate and etanercept in active, early, moderate to severe rheumatoid arthritis (COMET): a randomised, double-blind, parallel treatment trial". Lancet. 372 (9636): 375–82. doi:10.1016/S0140-6736(08)61000-4. PMID 18635256.
  3. ↑ Darzi A, Harfouche M, Arayssi T, Alemadi S, Alnaqbi KA, Badsha H, Al Balushi F, Elzorkany B, Halabi H, Hamoudeh M, Hazer W, Masri B, Omair MA, Uthman I, Ziade N, Singh JA, Christiansen R, Tugwell P, Schünemann HJ, Akl EA (October 2017). "Correction to: Adaptation of the 2015 American College of Rheumatology treatment guideline for rheumatoid arthritis for the Eastern Mediterranean Region: an exemplar of the GRADE Adolopment". Health Qual Life Outcomes. 15 (1): 214. doi:10.1186/s12955-017-0791-9. PMC 5658904. PMID 29073913.
  4. ↑ Goekoop-Ruiterman YP, de Vries-Bouwstra JK, Allaart CF, van Zeben D, Kerstens PJ, Hazes JM, Zwinderman AH, Ronday HK, Han KH, Westedt ML, Gerards AH, van Groenendael JH, Lems WF, van Krugten MV, Breedveld FC, Dijkmans BA (November 2005). "Clinical and radiographic outcomes of four different treatment strategies in patients with early rheumatoid arthritis (the BeSt study): a randomized, controlled trial". Arthritis Rheum. 52 (11): 3381–90. doi:10.1002/art.21405. PMID 16258899.
  5. ↑ van der Kooij SM, Goekoop-Ruiterman YP, de Vries-Bouwstra JK, Güler-Yüksel M, Zwinderman AH, Kerstens PJ, van der Lubbe PA, de Beus WM, Grillet BA, Ronday HK, Huizinga TW, Breedveld FC, Dijkmans BA, Allaart CF (June 2009). "Drug-free remission, functioning and radiographic damage after 4 years of response-driven treatment in patients with recent-onset rheumatoid arthritis". Ann. Rheum. Dis. 68 (6): 914–21. doi:10.1136/ard.2008.092254. PMID 18662933.
  6. ↑ Xu C, Peng H, Li R, Chai W, Li X, Fu J, Liu K, Yu B, Jia C, Chen J (October 2017). "Risk factors and clinical characteristics of deep knee infection in patients with intra-articular injections: A matched retrospective cohort analysis". Semin. Arthritis Rheum. doi:10.1016/j.semarthrit.2017.10.013. PMID 29129326.

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