Management Of Rheumatoid Arth... Health Article

Deciding What Therapeutic Approach To Use In Each Patient

Although all early RA patients require DMARD intervention, optimal DMARD management for each patient is an individual matter. Some patients with mild disease may respond with symptom control to a single DMARD, while those with poor prognosis disease may need early aggressive combination drug strategies. Clinical features and tests that help with this decision making process are summarized in Table 2. Most patients will commence single DMARD therapy with the exact agent dependent on the disease activity and severity. The commonly used conventional drugs and their monitoring requirements are summarized in Table 3. If rapid titration to maximum dose of a single agent fails to induce an adequate response, then the addition of a second or even third agent should be considered. A change in DMARDs is warranted if toxicity occurs or no benefit accrues. Methotrexate is now the most commonly used DMARD with a relatively high rate of response and the risk of toxicity is reduced by the coprescription of folic acid. Parenteral administration of methotrexate has been shown to be effective in over half of patients failing to respond to oral therapy. Other options in patients with poor prognosis disease include the addition of sulphasalazine and/or leflunomide, perhaps with the use of steroids to provide early symptom relief.

Using Steroids Optimally In The Course Of The Disease

Unlike NSAIDs, there is good evidence to show that steroids slow down the course of the disease. Over the short term they exert a profound effect on the symptoms of RA, but as a single agent they have limitations, with diminishing returns on symptom control over time. The adverse consequences of long term steroids are also well documented, with even low dose therapy often resulting in eventual osteoporosis.

The following rules should be applied to using steroids throughout the course of a patient’s RA.

• The most satisfactory method is to inject them straight into an inflamed joint. This usually results in rapid symptom relief, but is of limited benefit if the patient has an active polyarthritis.

• In a patient with active polyarthritis an intramuscular injection (e.g.120 mg methylprednisolone or triamcinolone acetonide) may help symptoms while waiting for the benefits of DMARDs to evolve over the ensuing 6 weeks.

Published regimens for RA include the use of high dose steroids that are then tapered down. However, these regimes also rely on other combinations of DMARDs being introduced simultaneously.

The decision to start oral steroids should not be taken lightly and should be left to the specialist team. Whenever there is difficulty in withdrawing steroids, this questions the efficacy of the DMARDs that are being employed.

Involving The Multidisciplinary Team Early And Throughout The Course Of The Disease

If drug regimens could eradicate RA and result in prolonged remission, then the need for other specialists would be reduced. However, sustained remission is not usually achieved with current treatment. All patients at a challenging and frightening time of their lives need the time and expertise of a wide variety of individuals.

• Specialist nurses, who can take patients through the details of drug regimes, side effects, and monitoring requirements.

• Physiotherapists, who can help with non-pharmacological pain relief, and introduce appropriate exercise, discussing the balance between activity and rest.

• Occupational therapists, who can provide resting splints for painful joints, and aids and assistance which maintain function, independence, and employment.

A key role of all of the professionals in early RA is education. Every patient needs to understand RA, and how they can help themselves. Evidence exists that educating patients with early RA is an independent predictor of good disease control. Orthopaedic surgery has a major role to play in joint reconstruction or replacement, but this indicates failure of medical treatment and thankfully fewer patients now require operative intervention.

Monitoring The Response To Treatment

It is important in early RA to monitor treatment response, and to modify therapy accordingly. This requires a combination of subjective and objective assessment which is both specific to active disease and sensitive to change. Most departments therefore use composite scores. The DAS (Disease Activity Score) is an amalgamation of the number of tender and swollen joints, the ESR, and a visual analogue score of the patient’s overall health. Although DAS has limitations, and cannot replace specialist assessment, it provides a comparable semi objective measurement of disease activity. A change in treatment should be considered where there is no improvement in disease activity.