Treatment options for RA

If you’re diagnosed with rheumatoid arthritis (RA), your doctor and rheumatologist will work with you to reduce painful symptoms and slow the progression of the disease.

Medication is often the first line of treatment for RA. Drugs include:

  • nonsteroidal anti-inflammatory drugs (NSAIDs)
  • corticosteroids
  • disease-modifying antirheumatic drugs (DMARDS)
  • biologic agents

Some doctors will administer a combination of drug therapies. This depends on your symptoms and the stage of the disease.

Discuss your medication options with your doctor to determine the best course of treatment for you.

People recently diagnosed with RA will likely receive a prescription for a DMARD such as:

In the past, doctors typically started people off with aspirin or NSAIDs to reduce pain and inflammation. Now, many doctors treat people more aggressively and earlier with DMARDS in an effort to prevent joint damage.

Two other categories of DMARDs used to treat RA are biologic response modifiers and JAK inhibitors. Biologics such as etanercept block tumor necrosis factor (TNF), which triggers inflammation.

A new category of drugs called Janus kinase (JAK) inhibitors fight inflammation within the cells. Tofacitinib is an example of one of these.

With so many drug options, doctors will work with you to determine the best combination of therapy to treat your RA.

In 2012, researchers led by Larry W. Moreland, M.D., studied oral triple therapy. The study looked at treatment of early aggressive RA over two years. The study became known by the acronym TEAR: treatment of early aggressive rheumatoid arthritis.

The people with RA in the study received one of four treatments:

  • initial treatment with MTX, plus etanercept
  • initial treatment with oral triple therapy: MTX, sulfasalazine, and hydroxychloroquine
  • a step up from initial MTX monotherapy to one of the above combination therapies
  • placebos

The TEAR study reported that both of the first two treatments were more effective than MTX monotherapy.

James R. O’Dell, M.D., at the University of Nebraska Medical Center in Omaha, has authored many studies of RA over the decades. He was a coauthor on the TEAR study.

In July 2013, O’Dell led a 48-week studyof 353 people with RA. Numerous coauthors joined O’Dell in this multinational effort.

All participants in the O’Dell study had active RA, despite earlier treatment with MTX. Investigators assigned treatment randomly, either:

  • triple therapy with MTX, sulfasalazine, and hydroxychloroquine
  • etanercept plus MTX

People who didn’t show improvement at 24 weeks were switched to the other group.

Both groups in the O’Dell study recorded significant improvement. Patients who didn’t respond to initial triple therapy were changed to etanercept and methotrexate. Doing so didn’t adversely affect their clinical outcomes. It also allowed them to be treated in a more cost-effective way.

MTX, sulfasalazine, and hydroxychloroquine are all older drugs. They provide a relatively inexpensive treatment option. Combining MTX with etanercept, a biologic that combines Enbrel and Immunex, is more expensive.

O’Dell told the European League Against Rheumatism Congress 2013 that while the two strategies provide comparable benefits, triple therapy is $10,200 cheaper per person per year.

O’Dell concluded that starting people off with triple therapy makes economic sense. He suggested that people with an unsatisfactory response switch to MTX and etanercept.

Dutch researchers also give a thumbs-up to triple therapy for lowering both direct and indirect costs in this study. They reported on 281 people newly diagnosed with RA in October 2013. The Rotterdam study is called tREACH.

Those on triple therapy needed less costly treatment. This is in part because they didn’t need costly biologicals to augment MTX. They also didn’t miss as much time from work because they were sick less.