Rheumatoid arthritis is the most common inflammatory form of arthritis. It affects approximately 2.1 million Americans. Here is the approach to management that we use at the Arthritis and Osteoporosis Center of Maryland.
o Make the diagnosis:
This means listening: We ask questions such as: How much stiffness do you have in the morning? How long does it last? How long have you had your symptoms? How fatigued are you? Do you have any painful joints? Any swollen joints? Any family history of rheumatoid arthritis?
This means looking: is there joint swelling? Which joints? Is the pattern symmetric (one side looking like the other)? Any joint redness? Any other associated symptoms such as dry eyes and mouth (which may signify Sjogren's syndrome, a condition that often accompanies rheumatoid arthritis)?
This means getting the appropriate tests:
Blood tests: Rheumatoid factor, Anti-nuclear antibody, Anti CCP, Erythrocyte sedimentation rate (sed rate), C-reactive protein, complete blood count, blood chemistries, thyroid function, urinalysis.
Imaging: Magnetic resonance imaging (MRI) or ultrasound to detect early inflammation and erosions (damage). Damage to the joints occurs within six months of onset!
o Start aggressive treatment:
Rheumatoid arthritis is the result of a self-perpetuating dysfunction of the immune system leading to overproduction of harmful chemical messengers called cytokines and chemokines. These harmful messengers lead to the excessive generation of destructive enzymes. The damage caused by these different enzymes involves many organ systems such as the joints, the lungs, the eyes, and the heart. In addition, the chronic inflammation causes further complications such as accelerated atherosclerosis (hardening of the arteries) leading to early heart attack and stroke. Another potential complication is the development of lymphoma (cancer of the lymph system).
So, the diagnosis of rheumatoid arthritis is considered a medical emergency and needs to be treated as such. This means disease modifying anti-rheumatic drugs (DMARDS). These drugs slow the progression of disease. The one we use most often is methotrexate. We also add low dose prednisone or perhaps a non-steroidal-anti-inflammatory drug (NSAID) to help with symptoms.
If a patient doesn't improve within a month to six weeks, we add a biologic drug. The purpose of these medicines is to get the disease into remission. The drug of choice is an anti-TNF drug like adalimumab (Humira), etanercept (Enbrel), or infliximab (Remicade).
If a patient doesn't respond to one of these within 2-3 months, we will switch to a different anti-TNF drug.
Within 2-3 months if a patient doesn't have optimal response to two different anti-TNF drugs, we will go to a second-line biologic treatment. There are two available. We try one first and if a patient doesn't respond we go to another.
One option is rituximab (Rituxan) which is a drug that targets B-cells. Another option is abatacept (Orencia) which is a drug that targets T-cells.
Periodic joint injection with corticosteroids occasionally is needed.
While all these medicines are being used we also recommend sufficient rest and once a patient starts to feel better, regular exercise. Joint protection is important as is proper nutrition. Proper nutrition and weight control are advised. Nutritional supplementation with anti oxidants is valuable.
Pain control with modalities such as acupuncture, physical therapy, massage, and low level (cold) laser can also be helpful.
Anti-inflammatory herbs and homeopathic agents also work well in conjunction with the above in many instances.
Adjunctive therapies such as hypnosis, guided visualization, meditation, and prayer are also frequently recommended.
Rheumatologists want to do more than control rheumatoid arthritis. We want to get it into complete remission. Fortunately, today, it is possible to do it.
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