Rheumatoid arthritis (RA) is the most common inflammatory form of arthritis and affects approximately 2 million Americans. A recent study has shown that the incidence of the disease may be declining somewhat; yet, RA still remains a significant public health problem. This is because of the multisystem nature of the disease. RA is a chronic, systemic, autoimmune condition for which there is no known cure.
It has the potential to affect multiple organ systems including the heart, lungs, eyes, bone marrow, skin, and peripheral nervous system.
The treatment of rheumatoid arthritis starts with making the diagnosis. Once the diagnosis is established, treatment may be started.
Symptoms of pain may be treated with non-steroidal anti-inflammatory drugs (NSAIDS). These help with symptoms but do nothing to modify the course of the disease.
Disease-modifying anti-rheumatic drugs (DMARDS) are medicines that have an effect on the disease itself. They slow down and sometimes stop the progression of disease. This is accomplished by acting on the immunologic disturbances that are responsible for RA.
Examples of DMARDS used to treat RA include hydroxychloroquine (Plaquenil), sulfasalazine (Azulfidine), azathioprine (Imuran), cyclosporine (Neoral), and methotrexate. The latter drug is considered the workhorse or base upon which all other disease modifying therapies are laid upon. These are generally administered as oral pills or tablets.
Most of these chemical DMARDS were originally used to treat other conditions before finding a niche in RA.
In addition to chemical DMARDS, newer biologic medicines, protein based drugs synthesized to specifically target immune abnormalities are also considered DMARDS. These biologics are administered either by subcutaneous injection or intravenously.
Thus, DMARDS are divided into two groups: non-biologic DMARDS and biologic DMARDS.
While the old approach was to use DMARDS late, the newer approach is to combine a chemical DMARD and a biologic early in the course of disease, generally within the first three months of disease activity. The reason is that that is when the best chance to obtain remission is. In fact, early treatment can actually lead to permanent remission in some cases.
All DMARDS have potential side effects including liver toxicity, bone marrow toxicity, and kidney damage, among others in the case of the chemical DMARDS.
Biologics increase the likelihood of infection, particularly tuberculosis and this mandates the need for screening and careful follow-up, central nervous system dysfunction, and many other potential problems.
Close supervision by an experienced rheumatologist is mandatory. This reduces the likelihood of problems.