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.
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: