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 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 q x month.
- 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:
- 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.
Various therapy used 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.[3][4]
- 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.[5]
Flares
- There is the severity of symptoms of ongoing treatment. We can add another DMARDs with methotrexate or replace with another DMARDs.
References
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.