The American College of Rheumatology (ACR) has updated its guidelines for the management of rheumatoid arthritis after just 5 years. The new guidelines, published in the February 2002 issue of Arthritis & Rheumatism, the journal of the ACR, take into account major research advancements and the development of new treatment options.
Over 2 million Americans suffer with the autoimmune disease, rheumatoid arthritis. The disease, characterized by symmetric, erosive synovitis (inflammation of the joints) and in some cases, systemic involvement (inflammation of other body organs) has an unpredictable course for most patients. In spite of treatment, it is still possible for progressive joint destruction to occur, as well as deformity, disability, and premature death.
The goal in the management of rheumatoid arthritis is to:
The initial steps in the management of rheumatoid arthritis are to:
If the primary care physician is uncertain about any of the initial steps, the ACR strongly recommends that an evaluation be done by a rheumatologist (a specialist in arthritis and related diseases).
The initiation of treatment begins with:
Patients taking DMARDS should be reassessed periodically for disease activity and toxicity of treatment. Patients on DMARDS experiencing repetitive flares, unacceptable disease activity (defined as ongoing disease activity following 3 months of maximum therapy) or progressive joint damage require consideration of changes to the DMARD regimen.
DMARDS commonly used to treat RA include hydroxychloroquine (plaquenil), sulfasalazine, methotrexate, leflunomide (Arava), etanercept (Enbrel), and infliximab (Remicade). Less commonly used DMARDS include azathioprine, D-penicillamine, gold salts, minocycline, and cyclosporine.
Many factors influence the selection of a particular DMARD. Initial selection of a DMARD is based on:
- relative efficacy
- convenience of administration
- requirements of monitoring program
- cost of medication and monitoring
Patient factors which should be assessed in selecting a DMARD:
- likelihood of compliance
- comorbid conditions
- severity and prognosis of patients disease
- physicians own confidence in administering and monitoring the drug
For many years, low cost treatment options existed for RA. With the advancements in research and the availability of newer NSAIDS (COX-2 Inhibitors), and the biologic agents (Enbrel, Remicade, and Anakinra), cost consideration has become an integral part of the decision when choosing between treatment options.
Efficacy and toxicity - if equivalent when comparing different treatment options, it is likely the lower cost agent will be used. Not all treatments are equivalent in response however, and a trial of the newer, more expensive drugs can be justified. What's different in the new guidelines is the issue of "how" these newest targeted drugs work, and also the issue of affordability.
Source: Guidelines For The Management Of Rheumatoid Arthritis - 2002 Update Online at American College of Rheumatology
