Rheumatoid arthritis medical therapy

Rheumatoid arthritis Microchapters
Home
Patient Information
Overview
Historical Perspective
Classification
Pathophysiology
Causes
Differentiating Rheumatoid arthritis from other Diseases
Epidemiology and Demographics
Risk Factors
Screening
Natural History, Complications and Prognosis
Diagnosis
Diagnostic Study of Choice
History and Symptoms
Physical Examination
Laboratory Findings
Electrocardiogram
X Ray
Echocardiography and Ultrasound
CT
MRI
Other Imaging Findings
Other Diagnostic Studies
Treatment
Medical Therapy
Surgical Therapy
Primary prevention
Secondary prevention
Future or Investigational Therapies
Case Studies
Case #1
Rheumatoid arthritis medical therapy On the Web
Most recent articles
Most cited articles
Review articles
CME Programs
Powerpoint slides
Images
American Roentgen Ray Society Images of Rheumatoid arthritis medical therapy All Images X-rays Echo & Ultrasound CT Images MRI
Ongoing Trials at Clinical Trials.gov
National Guidelines Clearinghouse
NICE Guidance
FDA on Rheumatoid arthritis medical therapy
CDC on Rheumatoid arthritis medical therapy
Rheumatoid arthritis medical therapy in the news
Blogs onRheumatoid arthritis medical therapy
Directions to Hospitals Treating Rheumatoid arthritis
Risk calculators and risk factors for Rheumatoid arthritis medical therapy

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.

Various 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 moderately to severely active RA.
• Abatacept:
  • It binds to CD80 and CD86 and inhibits T-cell activation, which further blocks interaction with CD28.
  • This is used for moderately to severely active RA.

DMARDs and TNF Inhibitors

• 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.
• Etanercept:
  • This is a bivalent p75–TNF receptor attached to the Fc portion of IgG human antibody.
  • Preferred dose: 25 mg SC 2 times weekly or 50 mg SC once weekly, with or without concomitant MTX.
• Golimumab:
  • This is a human monoclonal antibody to TNF-α which inhibits TNF-α bioactivity.
  • Preferred dose is 50 mg SC qxMonth.
• 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.
• Adalimumab: