Rheumatoid arthritis (RA) is the most common form of inflammatory arthritis affecting between approximately two million Americans. It is a systemic, chronic, autoimmune driven disorder that affects not only joints but internal organs as well. The disease has been associated with a significant mortality causing people affected by the disease to die 7-10 years before people who do not have RA. Also, it is associated with significant morbidity, meaning patients will suffer a loss of independence as well as the ability to continue to pursue gainful employment.
A prior set of guidelines from the American College of Rheumatology in 2008 laid out treatment recommendations and guidelines for starting and switching medications.
However, these guidelines were formulated before complete knowledge as to the effect of newer drugs on disease course was fully appreciated. Those of us in practice, of course, felt these guidelines were antiquated even as they were released.
The newer guidelines deal with new discoveries and also make recommendations about how to use biologic drugs in high risk patients. As a result, I think these guidelines do make more sense and support the treatment approach that most private practitioners already follow.
The key point that the authors made was that low disease activity or even remission should be the goal of treatment. This is a critical point. It is now possible to get most patients with RA into remission.
One of the major changes from the 2008 guidelines was the emphasis on more aggressive treatment in patients with early RA that is - the first 6 months of disease onset. The recommended change to more intensive early therapy is necessary since more aggressive early treatment can provide better outcomes.
It's no secret that early diagnosis and treatment makes a huge difference in patient outcome.
Since joint damage in RA is irreversible, prevention of damage is an important goal. In addition to the obvious joint issues, preservation of physical function and health-related quality of life is important in order to limit the likelihood of disability.
To that end, they recommend early institution of disease modifying anti-rheumatic drug (DMARD) therapy, drugs that slow the rate of progression of RA. Examples would be medicines like methotrexate and hydroxychloroquine (Plaquenil). Biologic drugs should be added quickly if DMARD therapy does not appear to be working effectively. Biologic drugs include the tumor necrosis factor (TNF) inhibitors adalimumab (Humira), certolizumab pegol (Cimzia), etanercept (Enbrel), golimumab (Simponi), or infliximab (Remicade). Non TNF biologics include abatacept (Orencia), tocilizumab (Actemra), or rituximab (Rituxan).
One other point: Biologics should not be combined since there is no increase in efficacy but there is an increase in side effects.
Finally, when I consider how far we've come with our approach to RA since I began practice in 1981, the difference is both astounding as well as gratifying.