By Dr Ananya Mandal, MD
Rheumatoid arthritis treatment is outlined in several guidelines worldwide. These include guidelines from ACR, EULAR, and the UK’s National Institute for Health and Clinical Excellence. It is to be remembered that rheumatoid arthritis has no absolute cure. It is a progressive disease. However, there are several approaches that can help in preventing and delaying the progress of the disease as well as improving the functional capacity of the patients to a great extent.
Aims of treatment
Treatment approaches and aims include:
Relief of symptoms
Preventing progression of joint damage
Preventing loss of function and preserving and making the best of existing joint function
Treatments of symptoms
Pain relievers and anti-inflammatory agents are the primary mode of therapy to relieving join pain and inflammation. Plain pain relievers that reduce pain but do not act on inflammation include opioids like codeine and fever relievers like paracetamol. These are not preferred in management of rheumatoid arthritis.
Non-steroidal anti-inflammatory drugs (NSAIDs) are the drugs used widely to control symptoms of rheumatoid arthritis. Over years NSAIDs have been replaced by other more effective agents in reducing joint inflammation. This is because of their limited efficacy, inability to alter or halt the progress of the disease and side effect profile.
NSAIDs are notorious is causing gastric ulcers, gastrointestinal complications, kidney damage and heart disease. When used they need to be administered with proton-pump inhibitors to reduce the gastric acid secretion.
Preventing progression of joint damage
This is achieved by the use of Disease-modifying anti-rheumatic drugs or DMARDs. These are a group of medications that are the mainstay of therapy for rheumatoid arthritis. These agents have a varied mechanism of action and they act by reducing joint swelling and pain, decreasing markers of acute inflammation in blood and halt the progressive joint damage. These agents thereby improve joint function.
Methotrexate – often the first drug given
Sulfasalazine – one of the commonest drugs used in rheumatoid arthritis
Hydroxychloroquine and Chloroquine
Gold (rINN sodium aurothiomalate)
These agents are sometimes used alone or in combination. For example methotrexate, sulfasalazine, and hydroxychloroquine are used as triple therapy.
DMARDs however are also associated with a varying degree of side effects. Some may be minor including nausea while other may be serious including liver damage, blood disorders and interstitial lung disease. Before therapy a thorough evaluation of general health and regular physical and laboratory checkups to detect potential side effects is thus important.
Another approach to preventing the progress of the disease is to use biological agents. TNF inhibitors were the first licensed biological agents including etanercept, infliximab, adalimumab and certolizumab. This was followed by monoclonal antibodies like abatacept, rituximab, and tocilizumab.
These are highly effective agents. These agents target the disease pathology rather than the symptoms and may lead to effective disease control. Biological agents are combined conventionally with methotrexate or leflunomide. Biologicals are usually given by injection. While some can be self-injected at twice weekly to monthly intervals, others need to be infused. Biologicals may cause adverse effects like injection site complications, allergic and hypersensitivity reactions as well as increased risk of infections like tuberculosis.
Glucocorticoids or steroids have been used in rheumatoid arthritis for over six decades. These agents are primarily anti-inflammatory and are thus useful in rheumatoid arthritis. When used for a short term these agents reduce inflammation of the cartilage and synovium in the joints. In the long term they decrease joint damage. Long term use however is fraught with side effects including infections and osteoporosis, risk of diabetes etc. Glucocorticoids are thus most used and useful in acute flare ups of rheumatoid arthritis. There is rapid improvement and this allows time for more slowly acting agents like DMARDs’ actions to set in. Glucocorticoids can be used here in oral or injectable forms.
This modality of treatment aims to preserve the joint function and limit disability. This includes exercise, joint protection, psychological support etc. Patient education forms a greater part of this approach. Adequate foot care, maintaining regular movements and use of the joints is vital.
This modality of therapy needs to be a multidisciplinary approach including a rheumatologist, orthopaedic surgeons, physiotherapists, physical medicine specialists, podiatrists, occupational and behavioral therapists and counsellors.
Supportive therapy also involves management of coexisting ailments like heart disease, bone diseases, lung disease, vasculitis, eye complications, kidney disease, anxiety and depressive disorders.
Surgery may be performed to retain joint function or prevent loss of joint function. Joint replacement therapy may be chosen. This is vital when joints fail. There are different types of surgery to correct joint problems. For example, in rheumatoid arthritis affected hands the ligaments and tendons may be released to ease the deformity. Surgeries of hands affected with rheumatoid arthritis include carpal tunnel release, removal of inflamed tissues from the finger joints etc. In severe cases the affected joints of the hips or knees may be replaced partly or completely to prevent further damage. This is called arthroplasty. Other joints that may be replaced include shoulder joints.
Physiotherapy is an important part of therapy of debilitating arthritis. This helps maintain optimum joint flexibility and strength. Pain relief may be offered using heat or ice packs, or transcutaneous electrical nerve stimulation (TENS). TENS uses a machine that applies a small pulse of electricity to the affected joint, which numbs the nerve endings and relieves pain.
Reviewed by April Cashin-Garbutt, BA Hons (Cantab)