Rheumatoid arthritis: management

Rheumatoid arthritis: management

The management of rheumatoid arthritis (RA) has been revolutionised by the introduction of disease-modifying therapies in the past decade.

Patients with evidence of joint inflammation should start a combination of disease-modifying drugs (DMARD) as soon as possible. Other important treatment options include analgesia, physiotherapy and surgery.

Initial therapy

• NICE recommend DMARD monotherapy +/- a short-course of bridging prednisolone
  Rheumatoid arthritis: initial management is conventional DMARD monotherapy (usually methotrexate), often with short-term bridging corticosteroid
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  Importance: 78
  . In the past dual DMARD therapy was advocated as the initial step
• choices for initial DMARD monotherapy:
  • methotrexate is the most widely used DMARD. Monitoring of FBC & LFTs is essential due to the risk of myelosuppression and liver cirrhosis. Other important side-effects include pneumonitis
  • sulfasalazine
  • leflunomide
  • hydroxychloroquine: should only be considered for initial therapy if mild or palindromic disease

Monitoring response to treatment

• NICE recommends using a combination of CRP and disease activity (using a composite score such as DAS28
  DAS28 is a measure of disease activity in rheumatoid arthritis
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  Importance: 2
  ) to assess response to treatment

Flares

• flares of RA are often managed with corticosteroids - oral or intramuscular
  flares of RA are often managed with corticosteroids - oral or intramuscular
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TNF-inhibitors

• the current indication for a TNF-inhibitor is an inadequate response to at least two DMARDs including methotrexate
• etanercept: recombinant human protein, acts as a decoy receptor for TNF-α, subcutaneous administration, can cause demyelination, risks include reactivation of tuberculosis
  TNF-#alpha# inhibitors may reactivate TB
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  Importance: 93
• infliximab: monoclonal antibody, binds to TNF-α and prevents it from binding with TNF receptors, intravenous administration, risks include reactivation of tuberculosis
• adalimumab: monoclonal antibody, subcutaneous administration

Rituximab

• anti-CD20 monoclonal antibody, results in B-cell depletion
• two 1g intravenous infusions are given two weeks apart
• infusion reactions are common

Abatacept

• fusion protein that modulates a key signal required for activation of T lymphocytes
• leads to decreased T-cell proliferation and cytokine production
• given as an infusion
• not currently recommend by NICE

+PassMedicine Notes

The management of rheumatoid arthritis (RA) has been revolutionised by the introduction of disease-modifying therapies in the past decade.

Patients with evidence of joint inflammation should start a combination of disease-modifying drugs (DMARD) as soon as possible. Other important treatment options include analgesia, physiotherapy and surgery.

Initial therapy

• NICE recommend DMARD monotherapy +/- a short-course of bridging prednisolone. In the past dual DMARD therapy was advocated as the initial step
• choices for initial DMARD monotherapy:
• methotrexate is the most widely used DMARD. Monitoring of FBC & LFTs is essential due to the risk of myelosuppression and liver cirrhosis. Other important side-effects include pneumonitis
• sulfasalazine
• leflunomide
• hydroxychloroquine: should only be considered for initial therapy if mild or palindromic disease

Monitoring response to treatment

• NICE recommends using a combination of CRP and disease activity (using a composite score such as DAS28) to assess response to treatment

Flares

• flares of RA are often managed with corticosteroids - oral or intramuscular

TNF-inhibitors

• the current indication for a TNF-inhibitor is an inadequate response to at least two DMARDs including methotrexate
• etanercept: recombinant human protein, acts as a decoy receptor for TNF-#alpha#, subcutaneous administration, can cause demyelination, risks include reactivation of tuberculosis
• infliximab: monoclonal antibody, binds to TNF-#alpha# and prevents it from binding with TNF receptors, intravenous administration, risks include reactivation of tuberculosis
• adalimumab: monoclonal antibody, subcutaneous administration

Rituximab

• anti-CD20 monoclonal antibody, results in B-cell depletion
• two 1g intravenous infusions are given two weeks apart
• infusion reactions are common

Abatacept

• fusion protein that modulates a key signal required for activation of T lymphocytes
• leads to decreased T-cell proliferation and cytokine production
• given as an infusion
• not currently recommend by NICE