Monday, August 19, 2013

Treating Early Rheumatoid Arthritis

Rheumatoid arthritis (RA) is the most common inflammatory form of arthritis affecting approximately two million Americans. It is a systemic, autoimmune disease for which there is no known cure.

Several pieces of data have shown that joint damage in RA can occur as early as 4 months after the start of symptoms. And further evidence has demonstrated that early intervention with the disease using disease-modifying anti-rheumatic drugs (DMARD) therapy improves signs and symptoms of the disease but also slows the rate of x-ray progression, a primary determinant of future disability. In addition, since it is a systemic disease, damage inflicted on the joints can also be accompanied by significant damage to other organ systems such as the lungs, eyes, bone marrow, skin, and nerves.

Guidelines from the American College of Rheumatology have suggested the prompt initiation of DMARD therapy within the first three months of diagnosis. Sometimes adding low dose prednisone - an oral corticosteroid- can help buy time by serving as a "bridge" until the DMARD begins to kick in. Combining methotrexate, the "workhorse" DMARD, with low dose prednisone can reduce disease activity, slow the rate of progression of disease, and prevent further physical disability.

One word of warning is that delay of treatment beyond three months from the time of diagnosis has grave consequences since there is a higher probability of joint damage and less likelihood of achieving remission in the future. Furthermore, joint damage, once it occurs, cannot be reversed. So, prevention is the key.

So a common sense paradigm has emerged for the management of early rheumatoid arthritis. This is a model which most rheumatologists increasingly are adhering to.

The first is early diagnosis. This, of course depends on early referral to a rheumatologist.

The second important point is to institute DMARD treatment, preferably with methotrexate, along with low dose prednisone immediately.

And the final approach is to use the "treat to target" model that has become in vogue recently. Treating to target implies the need for very tight control of the disease. This approach allows a patient to have a custom-tailored treatment program with the aim of establishing either low disease activity or complete remission. The achievement of the treatment target can be objectively made using various measurement tools, including joint counts, blood tests of inflammation, and various imaging techniques.

Such a treatment approach is not dissimilar to the treatment approaches for other serious chronic conditions such as hypertension and diabetes.

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