Medical management

Disease-modifying anti-rheumatic drug (DMARD)

• is the mainstay of medical management
• DMARDs can be
  • biologic
    • anti-TNF agents e.g. – Adalimumab, Etanercept
    • other biologic agents e .g – Rituximab, Abatacept
  • nonbiologic
    • commonly used – Methotrexate, Leflunomide, Hydroxychloroquine, Sulfasalazine
    • less commonly used – Penicillamine, gold sodium thiomalate, Cyclophosphamide
• the European League Against Rheumatism (EULAR) recommends that patients at risk of persistent arthritis should be started on DMARDs as early as possible (ideally within 3 months), even if they do not fulfil classification criteria for an inflammatory rheumatologic disease
• the main goal of DMARD treatment is to achieve clinical remission. Regular monitoring of disease activity, adverse events and comorbidities should guide decisions on choice and changes in treatment strategies to reach this target (2)

Other medical management include:

• pain relief
  • consider oral non-steroidal anti-inflammatory drugs (NSAIDs, including traditional NSAIDs and cox II selective inhibitors), when control of pain or stiffness is inadequate. Take account of potential gastrointestinal, liver and cardio-renal toxicity, and the person's risk factors, including age and pregnancy
  • when treating symptoms of RA with oral NSAIDs:
    • offer the lowest effective dose for the shortest possible time
    • offer a proton pump inhibitor (PPI), and
    • review risk factors for adverse events regularly.
  • if a person with RA needs to take low-dose aspirin, healthcare professionals should consider other treatments before adding an NSAID (with a PPI) if pain relief is ineffective or insufficient (1)
• glucocorticoids
  • offer short-term treatment with glucocorticoids for managing flares in people with recent onset or established disease to rapidly decrease inflammation (1)
  • in adults with established RA, only continue long-term treatment with glucocorticoids when:
    • the long-term complications of glucocorticoid therapy have been fully discussed, and
    • all other treatment options (including biological and targeted synthetic DMARDs) have been offered (1).

Reference:

1. National Institute for Health and Care Excellence (NICE) 2018. Rheumatoid arthritis in adults: management
2. Combe B et al. 2016 update of the EULAR recommendations for the management of early arthritis. Ann Rheum Dis. 2017;76(6):948-959.
3. MeReC Bulletin 2007;17(5):1-8.