The goals of RA treatment have evolved in the last decade. In the past, the best that a patient could hope for was decreased pain and stiffness. Today, thanks to more effective drugs and earlier, more aggressive treatment of RA, expectations are much higher. Your doctor's goals for treatment are multifold:
- Alleviating joint-related symptoms (such as pain, swelling, and stiffness)
- Preserving function and maintaining the greatest possible mobility of the affected joints
- Preventing deformity and disability
- Improving quality of life
- Reducing the secondary effects of RA, such as clogging of the arteries (atherosclerosis), thinning of the bones (osteoporosis), and infections
At each meeting with your doctor, you should discuss your progress toward these goals. The results of this discussion will affect the choice of treatment for your RA.
Choosing the right RA medication for you involves many factors. Long ago, the approach to RA was based on a “treatment pyramid.” Relatively weak medications, which served as the base of the pyramid, were used first. As symptoms worsened and only after considerable procrastination and delay, more effective medications (located higher up on the pyramid) might be prescribed. Such a gradual approach to the treatment of RA is now considered incorrect, and early, aggressive treatment of RA is now the norm. Experts have come to the conclusion that if they don't “hit it with their best shot” early on, the chances of long-term success in controlling the damage of RA will be greatly reduced.
Early, aggressive treatment of RA is now the norm. Experts have concluded that if they don't “hit it with their best shot” early on, the chances of long-term success in controlling the damage of RA will be greatly reduced.
For many patients, methotrexate is an excellent medication to start with, unless there is a specific reason not to use it. Methotrexate takes about a month to begin working. The process of gradually increasing the dose to achieve its maximum effectiveness might take a few more months. In a small number of patients, methotrexate can cause liver problems, so people who have a history of liver disease might not be able to take this medication. Also, because alcohol impairs liver function, people who drink alcoholic beverages regularly may not be good candidates for this medication. Methotrexate can cause birth defects or miscarriage, so it can be used only by women of childbearing potential who promise to employ reliable birth control.
For people with mild cases of RA, it is sometimes possible to prescribe medications that are “user friendly” in terms of the requirements for lab work (needed for monitoring) and follow-up office visits. Those medications might include NSAIDs, hydroxychloroquine, or sulfasalazine. There are many possible exceptions or special circumstances that might influence which particular medication is chosen for a particular person.
For many people with RA, a combination of medications is needed to control their disease. The general goal with such combination therapy is to maximize the benefits and minimize the side effects by using smaller doses of several medications instead of a larger dose of a single medication. Some combinations of medications show extra benefit when they are combined—that is, they act synergistically.
Many combinations of medications are possible, but relatively few firm guidelines have been established regarding how to combine these medications. The combination of methotrexate, hydroxychloroquine, and/or sulfasalazine is a popular choice. Azathioprine or leflunomide might also be added; because these medications and methotrexate share some side effects in common, however, there is at least a theoretical concern about additive toxicity with this regimen.
Prednisone is a powerful anti-inflammatory medication with a rapid onset. Indeed, patients often feel better after taking this steroid for just a few days. It is frequently used in combination with other RA medications. Prednisone is particularly helpful early in the treatment course, because many other RA drugs take weeks to months to reach their maximal effectiveness. Once the slower-acting medications (such as methotrexate) have had a chance to work, the prednisone dose can be gradually decreased. Because prednisone has the potential to produce numerous side effects, including weight gain, doctors usually advise, “The smallest possible dose, for the shortest duration of time.” Nevertheless, this type of medication works so well that many people with RA remain on small doses of prednisone for long periods of time.
If a combination of these medications doesn't control the patient's RA symptoms or isn't tolerated because of side effects, the next step is to add one of the newer biologic medications—specifically, tumor necrosis factor (TNF) inhibitors, such as etanercept, adalimumab, or infliximab. Which biologic agent is used first depends on many factors, including your ability to inject yourself with the medication, your willingness to get an IV infusion, and your insurance company's willingness to pay for a particular medication. You should discuss the pros and cons of each medication with your doctor before beginning treatment.
These anti-TNF medications are typically used in combination with methotrexate. If one of the TNF inhibitors fails to produce acceptable results, another TNF inhibitor or one of the other biologic medications (such as kineret, abatacept, or rituximab) might be substituted into the drug regimen. Biologic medications are rarely used in combination with each other because of concerns about the increased risk of suppression of the body's immune system, which might lead to infections.
The early use of effective RA medications alone or in combination has enabled us to make great strides in our management of RA. Vast improvements have already been made, and more progress is likely in the future.