Best Strategy for Treating Rheumatoid Arthritis

Do you suffer from the painful effects of rheumatoid arthritis (RA)? Or do you know someone who does -- perhaps a close friend, loved one, or family member? If you answered 'yes' to either of those questions, then you will be interested in this update on medications to treat this problem.

Many new drugs are out on the market now specifically for rheumatoid arthritis. These medications have made it possible for many, many arthritis sufferers to experience remission.

Remission refers to the absence of any signs of the disease. No symptoms means improved function and increased activity. That is good news for anyone who previously couldn't even zip up their own pants or pick up a cup of coffee.

Treatment for RA has changed quite a bit in the past 10 to 15 years. Studies show that patients get better results if their disease is treated early and aggressively. Early is easy to understand. What does 'aggressively' mean?

Aggressive treatment starts with the use of medications called disease modifying anti-rheumatic drugs or DMARDs. Many patients are familiar with the most commonly prescribed DMARD: methotrexate or MTX. MTX has been around since the mid-1980s. But it wasn't always recommended right away because of concerns about toxicity. Only those patients with severe, advanced disease were given this drug.

Now we know that adverse responses to methotrexate (MTX) are much less than feared and the drug offers enough benefit to make it worth taking. Improved symptoms means better quality-of-life all the way around. And even better than that, disease modifying anti-rheumatic drugs (DMARDs) have been shown to slow and even stop joint destruction.

Today's best care starts patients on methotrexate (MTX) right away. Aggressive treatment requires taking methotrexate (MTX) at increasing dosages over a period of three to six months until the patient has gotten the best (maximum) response. Response is monitored closely. Anyone who is not getting the desired or expected results by the end of six months' time will be given another DMARD or possibly one of the newer biologic agents (more on biologic agents in a minute).

Monitoring patient response is considered a key part of the management process. Aggressive treatment calls for getting results early and quickly. The best way to know if the desired results are achieved involves measuring seven areas: number of tender joints, number of swollen joints, function, pain, patients' perception of their own health, physician assessment of the patient's progress, and lab values.

Lab values are useful because blood tests show levels of inflammation and changes in those markers as a result of taking meds. Physicians also have a tool called the disease activity score (DAS) to help monitor disease activity. It's a bit cumbersome and complicated to use, so a newer (easier-to-use) tool called the RAPID3 instrument is being tested for validity and reliability.

In the past, a lack of response or less than optimal response would have meant stopping the MTX and starting a new drug. The approach taken was called monotherapy (one drug at a time). Now, physicians know the best next step is to combine drug therapies (combination therapy). The patient keeps taking MTX but adds a second DMARD such as sulfasalazine (SSZ) or hydroxychloroquine (HCQ).

If that doesn't work, a biologic agent may be added to the mix. Biologic agents include etanercept, infliximab, adalimumab, and abatacept. These drugs fall into a category called tumor necrosis factor-alpha inhibitors or TNF-alpha inhibitors.

Many studies have shown that combining methotrexate (MTX), plus one other DMARD along with one of these biologic agents gives much better results than monotherapy with just one or the other. Taking all three types of medications is referred to as triple therapy.

About 85 to 90 per cent of all patients with rheumatoid arthritis are helped greatly by monotherapy with MTX, combination therapy with MTX plus another DMARD, or triple therapy with MTX, DMARD, and a biologic agent. That still leaves 10 to 15 per cent of patients who don't respond facing a future of painful disability.

That sounds discouraging but the good news is that there are new medications coming out that have a different mode of action (MOA). New TNF-alpha inhibitors (abatacept, rituximab) and an interleukin-6 blocker (tocilizumab) are now available to try. And if those don't work, more new medications are in the pipeline soon to be on the market.

In summary, rheumatologists and primary care physicians have new and improved tools to help treat patients with rheumatoid arthritis. Best care defined as "care you would give your mother" is the motto.

With the new disease modifying anti-rheumatic drugs and biologic agents on the market, Mom (and everyone else with this disease) can remain pain-free, active, and even disease-free for much longer than ever before. And that is the new "gold standard" of care!

Reference: Yusuf Yazici, MD. Rheumatoid Arthritis 2010: Treatment and Monitoring. In The Journal of Musculoskeletal Medicine. October 2010. Supplement. Pp. S20-S23.

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