Is Early, Aggressive Treatment Recommended For Rheumatoid Arthritis Patients?

Question: Is Early, Aggressive Treatment Recommended For Rheumatoid Arthritis Patients?

Is early, aggressive treatment recommended for newly diagnosed rheumatoid arthritis patients? Has there been a change over the years from a conservative approach to an aggressive approach? What is the usual course of treatment for a newly diagnosed patient? When are changes made to the initial course of treatment?

Answer:

Why Is Early Treatment For Rheumatoid Arthritis Important?

Early diagnosis of rheumatoid arthritis is emphasized to patients and doctors because early treatment with DMARDs and biologics may help prevent joint damage and subsequent disability. The reason for this more aggressive approach is that in the past, up to 30% of patients with rheumatoid arthritis for 2-3 years would become disabled.

Is Early Treatment Necessary For All Rheumatoid Arthritis Patients?

Fortunately, not all patients with rheumatoid arthritis are at risk for joint damage and disability. As a result, not all patients with rheumatoid arthritis need to be treated aggressively.

While NSAIDs (nonsteroidal anti-inflammatory drugs) may help the symptoms of rheumatoid arthritis, there is no evidence that they help prevent joint damage.

Less than 10% of patients with rheumatoid arthritis are candidates for treatment with NSAIDs alone. In general, patients at low risk for joint damage are often treated with agents that may have a low potential for side effects including:

• Plaquenil (hydroxychloroquine)
• Azulfidine (sulfasalazine)
• Minocin (minocycline - antibiotic that has shown benefit in rheumatoid arthritis, but is not FDA approved for this indication)

What Treatments Are Prescribed For Moderate To Severe Rheumatoid Arthritis?

Medications used for moderate to severe rheumatoid arthritis include the following, with other new drugs in development or ready to be marketed:

• methotrexate (Rheumatrex, Trexall)
• Arava (leflunomide)
• Imuran (azathioprine)
• Enbrel (etanercept)
• Remicade (infliximab)
• Humira (adalimumab)

Patients with this degree of arthritis have more problems or potential problems with activities of daily living as well as a higher risk of developing joint damage and disability. Due to its long term use and low cost, many rheumatologists will start with methotrexate as the initial DMARD in this group of patients. Prednisone in low doses may also have some disease modifying benefit.

For those patients with moderate to severe disease who have failed these drugs, the newer agents Orencia (abatacept) and Rituxan (rituximab) will be prescribed.

What Signs And Symptoms Are Associated With Joint Damage?

The following represent some of the clinical findings that may indicate an increased risk of joint damage and subsequent disability:

• Joint swelling
• Prolonged morning stiffness
• Onset at a younger age
• Very high CCP antibody
• Very high rheumatoid factor
• Rheumatoid nodules
• Elevated C-reactive protein (CRP) and sedimentation rate
• Radiographic abnormalities (x-rays)

Unfortunately, it is not possible to always predict who will or will not develop joint damage. As a result, if you have signs or symptoms of rheumatoid arthritis, make sure you have a consultation with a rheumatologist to find the treatment that would be best for you.

_{Dr. Zashin is clinical assistant professor at University of Texas Southwestern Medical School and an attending physician at Presbyterian Hospitals of Dallas and Plano. Dr. Zashin is author of Arthritis Without Pain - The Miracle Of TNF Blockers. The book is useful for anyone on one of the biologic drugs or considering the biologic drugs.}