Rheumatoid Arthritis (RA) Treatment

Nonpharmacologic Therapy

• All patients should receive education about nonpharmacologic and pharmacologic measures to help manage RA and JIA
• Occupational and physical therapy can help patients preserve joint function
• Patients should be counseled about stress management
• Surgery to replace or reconstruct the joint may be necessary if the disease has progressed to a severe form with extensive joint erosions

Pharmacologic Therapy

• The current standard of care for RA treatment is to initiate disease-modifying therapy immediately
• "Bridge therapy" or short-term use of certain medications can provide symptomatic relief until the disease-modifying drug reaches its therapeutic effect
• NSAIDs and glucocorticoids are commonly used for bridge therapy

NSAIDs

• Provide analgesic and anti-inflammatory benefits for joint pain and swelling
• Do not prevent joint damage or change the underlying disease
• Selection of an NSAID depends on patient-specific factors, including cardiovascular risk and potential for GI-related adverse events

Glucocorticoids

• Low-dose glucocorticoid treatment can reduce inflammation through inhibition of cytokines and inflammatory mediators
• Can prevent disease progression
• Recommended duration is 3 months or less to avoid significant adverse reactions, especially bone loss leading to osteoporosis
• Intra-articular administration of glucocorticoids may be considered in RA for rapid control of inflammation

Conventional Synthetic (cs)DMARDs

• Methotrexate is the csDMARD of choice in RA due to its efficacy and safety profile
• Once-weekly doses should be initiated and increased steadily until the patient has symptomatic improvement or a maximum dose of 20 mg/week is reached
• Concomitant folic acid is given to reduce the risk of folate-depleting reactions induced by methotrexate therapy

Treatment

• Desired outcomes of treatment in RA include reducing or eliminating pain, reducing disease activity, protecting articular structures and function, controlling systemic complications, and improving/maintaining quality of life
• Early diagnosis and early aggressive treatment are necessary to reduce disease progression and prevent joint damage

DMARDs

• DMARDs are the mainstay of RA treatment because they modify the underlying disease process
• The umbrella term DMARD includes conventional synthetic (csDMARD), biologic (bDMARD), and targeted synthetic (tsDMARD)
• Methotrexate is the initial treatment of choice for moderate to high disease activity
• Combination therapy may be initiated at the time of diagnosis, but combination bDMARDs or tsDMARDs should be avoided due to the increased risk of infection