Management Of Rheumatoid Arth... Health Article

Abstract

The management of rheumatoid arthritis (RA) has changed substantially over recent years. The emphasis is now on making an early diagnosis of RA, which still relies largely on clinical experience. When determining which treatment is most appropriate, clinical and laboratory markers on disease prognosis act as a guide. The choice of single or combination disease modifying drug therapies (DMARDs) has to be tailored to the individual patient. Steroids can act as DMARDs but are not a good long term choice as single therapy for most patients. A multidisciplinary team is important, and patient education is vital. The team needs to assess the response to treatment and modify it if it is less than satisfactory. Anti-TNF drugs have had a big impact on the management of RA not responding to conventional DMARDs, but in the UK their use has been restricted by cost to patients who have failed on 2 DMARDs with ongoing active disease. It is sometimes possible to reduce therapy in patients who are doing well, but whether DMARDs can be safely stopped in all patients in remission is highly contentious. In the future it is hoped that there will be progressive improvements in early diagnosis, better prognostic markers and that health economic arguments will be able to extend the eligibility for anti-TNF drugs so that these will make remission the rule and not the exception.

• Data have emerged to show that early recognition and aggressive intervention for RA does make a long-term difference to prognosis

• Anti-TNF drugs have revolutionized the lives of many patients who have failed on conventional DMARDs

• Remission for most patients used to be an unachievable aspiration, whereas nowadays it is a realistic goal

Over the past twenty years the management of rheumatoid arthritis (RA) has undergone dramatic changes, particularly in the past five years. Traditionally, RA was diagnosed late in the disease course, the symptoms were treated without addressing the underlying damaging nature of RA, referral to specialist teams was delayed, and drugs that might slow the disease process down (disease modifying anti-rheumatic drugs (DMARDs)) were introduced after joints had eroded. These management features should now be historical relics. However, there are still challenges in managing RA ( Table 1).

Making An Early Diagnosis

There is abundant evidence to show that the need for DMARDs is urgent in early RA. To do nothing will lead to an inevitable painful functional and structural decline in the great majority of patients. To just treat with anti-inflammatories and analgesics is inadequate, as these drugs do nothing to slow the disease process down. Although symptom relieving medication is vital, and pain control may be the top priority for patients, this has to be combined with drugs that have the potential to prevent disease deterioration. Consequently, early diagnosis of RA is vital to access early appropriate management.

In patients who present with a dramatic crippling symmetrical peripheral polyarthritis with high levels of inflammation and rheumatoid factor on investigation, there is rarely diagnostic doubt, and both patient and clinician will see aggressive intervention as a high priority. The greater challenge may be in patients with an insidious onset of symptoms with no dramatic evidence of synovitis, and investigations showing no abnormalities. The diagnosis of early RA is largely a clinical skill, with a suggestive history combined with evidence of early symmetrical small joint synovitis (e.g. metacarpophalangeal joints). All patients with early RA need to know they are in capable hands, and understand the rationale behind introducing powerful drugs promptly. A patient with normal investigations may still require urgent DMARDs on the basis of an expert history and examination.