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Treatment

Introduction

The treatment of rheumatoid arthritis (RA) has made dramatic strides in recent years, allowing people to not just live—but thrive—with the disease. Historically, RA treatment consisted of aspirin and a wheelchair, but ongoing development of new and innovative treatment approaches has changed the face of the disease.  New drugs and treatment approaches allow many people to live with less pain and better function. RA is a lifelong condition, but with regular monitoring and effective treatment you can manage your symptoms and live well.

The treatment of RA is a multifaceted process that may include medication, occupational therapy, physical therapy, and sometimes surgery. The main goals of treatment are to control inflammation and slow or stop the progression of RA. Early, aggressive treatment provides the best results.

Treatment of RA can be somewhat of a moving target. It will evolve based on your current set of symptoms and stage of disease. Treatment may seem confusing or overwhelming at first, but once you learn more about RA and its treatment and start to understand your own symptom profile, you’ll be able to work with your doctor to refine the optimal treatment plan for you.

Occasional shifts in treatment may be necessary to achieve maximum control of your RA, so don’t be surprised if your doctor makes a change to your drug dosage, adds a drug or drugs, or changes to an entirely new type of drug. Throughout this process you will be closely monitored in order to determine how treatment is working for you. You can help with this process by keeping your doctor well informed about your RA symptoms and any medication side effects that you experience.

Measuring Disease Activity

The more you and your doctor know about your RA, the better you can manage it. Your doctor will regularly monitor your disease activity, which is the term used to refer to ongoing inflammation, symptoms, and/or joint damage. This regular and systematic monitoring is critical to managing the condition.[1] Information about the level of disease activity allows doctors to monitor your response to treatment and to adjust your treatment as needed.

One commonly used measure of disease activity is the DAS28 (Disease Activity Score with 28 joint counts). The DAS28 involves a count of tender and swollen joints, your own assessment of your health, and lab tests to identify inflammation. The lab tests measure the erythrocyte sedimentation rate (ESR) or levels of C-reactive protein (CRP). Other composite measures of RA disease activity are also available.1

A newer way to measure disease activity is with the Vectra DA test, which is an innovative blood test that allows doctors to test for several biological markers (or biomarkers) of RA simultaneously. The test must be ordered by a physician. Vectra DA measures the levels of 12 proteins in the blood—biomarkers that have been linked to RA disease activity—and then combines them into a single score (between 1 and 100) that classifies your current level of RA disease activity as “low”, “moderate”, or “high”. The test does not replace a doctor’s evaluation, but it does provide a precise, objective measure of the underlying biology of your RA. Testing with Vectra DA can provide snapshots of your disease activity at specific points in time, which can help you and your doctor to better manage your RA.

Treating to Target

An important concept in the management of RA is “treating to target.”[2] This means that you and your doctor will identify and clearly define a treatment goal at the start of treatment and then choose treatment with this target in mind. Your doctor will continue to regularly monitor your disease activity in order to determine whether the target has been reached. If the target is not reached in a pre-specified period of time, treatment may need to be adjusted. The adjustment may be a change in the dose of current medications, or a switch to a new type of drug.

The target for most patients will be disease remission (little or no active RA).[3] The disease activity measures discussed above are used to assess progress toward this goal. As patients are working their way toward remission, monitoring of disease activity generally takes place at least every three months. In some cases, more frequent monitoring is necessary. Once the treatment goal has been reached, monitoring may be performed less frequently, but is still done on a regular basis.2 By staying on top of your RA, you and your doctor will be able to keep it under the tightest control possible.

RA Medications

Advances in our understanding of RA have led to earlier and more aggressive treatment of this condition. Because it is now recognized that joint damage begins early in the course of disease, early use of drugs that alter the course of RA (and that allow more patients to achieve a remission) has now become common.[4] Several different types of RA drugs are available, and decisions about which drug or combination of drugs to use will depend on your particular situation. Your rheumatologist will work with you to develop an individualized treatment plan.

During treatment, make sure that all of your healthcare providers are informed about all of your medications. This includes prescription medications, over-the-counter medications, and dietary supplements. Some products may not be safe to combine with your RA medications.

Drugs that are commonly used in the treatment of RA include the following:

DMARDs: Treatment of RA often begins with a type of drug known as a disease-modifying antirheumatic drug (DMARD). These drugs do more than just relieve painful, swollen joints: they also help to slow the progression of RA. Methotrexate is a commonly used DMARD, but several other options are available as well. In some cases, a combination of DMARDs may be used. These drugs are taken orally (by mouth). It generally takes a few weeks or months for them to take effect.

Side effects vary; for methotrexate, possible side effects include nausea, abnormal liver function tests, mouth sores, rash, diarrhea, changes in blood cell counts, lung problems, and sun sensitivity.

Biologics: If initial treatment does not adequately control the RA (or if patients have more serious RA), treatment may involve a newer type of RA drug known as a biologic.4 Biologics interfere with specific parts of the immune system that drive inflammation. Currently available biologics include Remicade® (infliximab), Humira® (adalimumab), Cimzia® (certolizumab), Simponi® (golimumab), Enbrel® (etanercept), Actemra® (tocilizumab), Kineret® (anakinra), Orencia® (abatacept), and Rituxan® (rituximab). Depending on the drug, biologics are injected either under the skin or into a vein. Biologics may be used in combination with methotrexate or another RA drug.

Side effects depend on the type of drug used. Drugs known as TNF inhibitors are often (but not always) the first type of biologic used. These drugs include Enbrel, Remicade, Humira, Simponi, and Cimzia. Possible side effects include serious infections and heart problems. These drugs may also increase the risk of certain types of cancer, such as lymphoma and non-melanoma skin cancers.

Steroids: Steroids known as glucocorticoids may be used on short-term basis to reduce joint inflammation. Depending on the situation, they may be taken orally, injected into a muscle, or injected directly into an affected joint. Steroids can rapidly improve symptoms, and may be especially useful during a flare-up of symptoms or while waiting for a slower-acting drug (such as the DMARDs) to take effect.[5]

Possible side effects of steroids include bone loss, weight gain, cataracts, and increases in blood sugar and blood pressure. Long-term use carries a greater risk of side effects than short-term use.

NSAIDs: Non-steroidal anti-inflammatory drugs (NSAIDs) include drugs such as aspirin, ibuprofen, and the COX-2 inhibitors. Some of these drugs are available over the counter and some require a prescription. NSAIDs provide pain relief and can also help to reduce inflammation. They are generally not the primary treatment used for RA because they do not improve the long-term course of RA in the way that DMARDs and biologics do.

Some NSAIDs can cause problems such as gastrointestinal bleeding, and people who use these drugs on a regular basis may also be prescribed medication to help protect their gastrointestinal tract.5 Certain types of NSAIDS also have cardiovascular risks.

Complementary Therapies

Complementary therapies are treatments that are used in addition to conventional therapies such as RA medications. These treatments do not replace conventional therapy, but there’s hope that they could improve well-being and ability to function.

Thus far, there is limited evidence that any type of complementary therapy provides a benefit,[6] but research in this area is ongoing. Treatments that have shown promise and that warrant additional research include mind-body therapies and certain dietary supplements.[7] Mind-body therapy may provide both physical and psychological benefits by reducing pain, improving physical function, and improving ability to cope. Examples of mind-body therapy are relaxation, meditation, tai chi, imagery, and biofeedback. Acupuncture may also help to manage pain, but there is limited information about its role in RA specifically.

Several types of dietary supplements are also being evaluated in RA. Fish oil supplements, for example, provide omega-3 fatty acids that may be useful at relieving joint tenderness and morning stiffness. Benefits of dietary supplements remain uncertain, and before taking any dietary supplement you should discuss it with your doctor. Some supplements may not be safe to use in combination with other medications or in people with certain health conditions.

Joint Surgery for RA

If joint damage becomes severe, surgery on the affected joint may relieve pain and (in some cases) improve joint function. Joint replacement, for example, involves removing a damaged joint and replacing it with an artificial one. This can reduce pain while also preserving or improving the function of the joint. Another procedure—joint fusion—involves fusing together the bones in a joint. This eliminates the ability of the joint to move, but provides stability and pain relief. Surgery may also be used to repair or remove damaged tissue.[8]

The Importance of Clinical Trials

Newer approaches to the treatment of RA have improved outcomes for many people but are not effective for everyone. Additional progress in the treatment of RA will come from clinical trials that test new drugs or new ways of managing symptoms or side effects. These studies involve large numbers of RA patients at many locations throughout the United States. Some studies focus on people with newly diagnosed RA, and others focus on people who have persistent symptoms in spite of prior RA treatment. As someone with RA, you may be eligible to participate in one of these studies. To learn more about clinical trials, talk with your rheumatology care team or visit ClinicalTrials.gov.

Promising new treatments that are currently being evaluated in clinical trials include drugs known as kinase inhibitors. Kinases are enzymes that help to relay messages within cells. Some kinases play a role in inflammation and RA, including the JAK (janus kinase) family of kinases and Syk (spleen tyrosine kinase). Drugs that inhibit these kinases may provide an effective new option for RA treatment, with the added advantage of being taken orally (by mouth). Other promising new treatment approaches are also being evaluated.

Summary

Although many people continue to be profoundly affected by RA, important progress had been made in managing this condition and additional progress is on the horizon. New approaches to treating RA—in combination with close and regular monitoring of disease activity—are slowing the progression of this disease and allowing some people to achieve a remission. There is still no “cure” for RA, but we may gradually be getting the upper hand.

References:

[1] Anderson J, Caplan L, Yazdany J et al. Rheumatoid arthritis disease activity measures: American College of Rheumatology Recommendations for Use in Clinical Practice. Arthritis Care & Research. 2012;64:640-647.

[2] Smolen JS, Aletaha D, Bijlsma JWJ et al. Treating rheumatoid arthritis to target: recommendations of an international task force. Ann Rheum Dis. 2010;69:631-637.

[3] Felson DT, Smolen JS, Wells G et al. American College of Rheumatology/European League Against Rheumatism Provisional Definition of Remission in Rheumatoid Arthritis for Clinical Trials. Arthritis & Rheumatism. 2011;63:573-586.

[4] Singh JA, Furst DE, Bharat A et al. 2012 update of the 2008 American College of Rheumatology recommendations for the use of disease-modifying antirheumatic drugs and biologic agents in the treatment of rheumatoid arthritis. Arthritis Care & Research. 2012;64:625-639.

[5] Scott DL, Wolfe F, Huizinga TWJ. Rheumatoid arthritis. The Lancet. 2010;376:1094-1108.

[6] Macfarlane GJ, El-Metwally A, De Silva V et al. Evidence for the efficacy of complementary and alternative medicines in the management of rheumatoid arthritis: a systematic review. Rheumatology (Oxford). 2011;50:1672-83.

[7] National Institutes of Health, National Center for Complementary and Alternative Medicine. Get the facts: rheumatoid arthritis and CAM. Last updated October 2010.

[8] National Institutes of Health, National Institute of Arthritis and Musculoskeletal and Skin Diseases. Handout on Health: Rheumatoid Arthritis. Last revised April 2009.

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