Rheumatoid Arthritis: Aggressive New Treatment Guidelines
Lucy Gong, PharmDNortheastern University Bouvé College of Health Sciences and Cubist Pharmaceuticals
Myra C. Wooley, PharmDNortheastern University Bouvé College of Health Sciences and Cubist Pharmaceuticals
Chad E. Glasser, PharmDNortheastern University Bouvé College of Health Sciences and Cubist Pharmaceuticals
J. Brock Bumpass, PharmDNortheastern University Bouvé College of Health Sciences and Cubist Pharmaceuticals
John Sekab, PharmD Candidate
J. Andrew Skirvin, PharmD, BCOPAssociate Clinical ProfessorNortheastern University Bouvé College of Health SciencesBoston, Massachusetts
DISCLAIMER: L.G., M.C.W., C.E.G., and J.B.B. are employed by Bouvé College of Health Sciences as postdoctoral fellows with Cubist Pharmaceuticals, Inc.
US Pharm. 2014 39:3-7.
ABSTRACT: Rheumatoid arthritis requires early intervention to prevent long-term complications and morbidity. The exact trigger is unknown, but symmetrical synovitis in the small joints of the hands and feet is the primary presentation. Recently published guidelines featuring new, more aggressive treatment recommendations discuss disease-modifying antirheumatic drugs, new biologic agents, and methods of switching between them. The most effective medications have numerous side effects, particularly immunosuppression. In order to achieve higher response rates, it will be necessary to develop additional therapeutic options with novel mechanisms.
Drugs For Rheumatoid Arthritis
As part of rheumatoid arthritis treatment, your doctor will probably prescribe a nonsteroidal anti-inflammatory drug . These medications reduce pain and inflammation but donât slow RA. So if you have moderate to severe RA, youâll probably also need to take other drugs to prevent further joint damage.
Many come as pills or tablets. Over-the-counter NSAIDs include ibuprofen and naproxen. Most people with RA need a prescription version, like celecoxib , as they offer a higher dose with longer-lasting results and require fewer doses throughout the day.
Prescription NSAIDs carry a warning about the higher risk of heart attack and stroke. NSAIDs can also raise blood pressure and can cause stomach irritation, ulcers, and bleeding.
You and your doctor can weigh the benefits of NSAIDs against the potential risks. You may have to try a few to find the one thatâs right for you.
DMARDs
This stands for disease-modifying antirheumatic drugs. They curb your immune system to help slow RA or keep it from getting worse.
Doctors usually first prescribe methotrexate to treat rheumatoid arthritis. If that alone doesnât calm the inflammation, they may try or add a different type of DMARD such as hydroxychloroquine , leflunomide , sulfasalazine , or tofacitinib .
You can take DMARDs as a pill, but some people get methotrexate as a shot. It may take a few weeks or months for them to start to work, and longer to get the full effect.
Biologics
Who Should Diagnose And Treat Ra
A doctor or a team of doctors who specialize in care of RA patients should diagnose and treat RA. This is especially important because the signs and symptoms of RA are not specific and can look like signs and symptoms of other inflammatory joint diseases. Doctors who specialize in arthritis are called rheumatologists, and they can make the correct diagnosis. To find a provider near you, visit the database of rheumatologistsexternal icon on the American College of Rheumatology website.
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What Other Risk Factors May Increase Your Likelihood Of Experiencing Ra
* Gender: Women are much more likely to suffer from this autoimmune disorder.* Weight: Overweight individuals are more prone to developing RA.* Smoking: If you smoke, you are more likely to develop RA, and if you develop it, your symptoms may be more pronounced than those who do not smoke.* Age: RA is more likely to hit you in middle age * Environment: Certain environmental exposures have been found to elevate your risk of RA, including exposure to asbestos and silica.
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Finding The Right Ra Treatment
Getting relief from the pain of severe RA starts with a visit to an experienced rheumatologist. The doctor can start you on medication and adjust the drug and dose until your symptoms and joint damage start to improve.
A year after his diagnosis, Melendez says his medications have dramatically improved his rheumatoid arthritis symptoms. âItâs a big difference,â he says. âI guess Iâm never going to be 100%, where I say thereâs no pain. But compared to what it was in the beginning, itâs like 90% better.â After taking a short break from work, he says he feels well enough to get back on the job.
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Stages Of Rheumatoid Arthritis
There are four stages. Each has its own treatment options.
Stage 1:
- In the early stages, your joint lining, or synovium, becomes inflamed. The bones arenât damaged yet. But the tissue around them often swells, making your joint stiff and painful.
Stage 2:
- In this moderate stage, inflammation damages your cartilage, the cushiony stuff that protects the ends of your bones.
- The joint will be stiff, and you wonât be able to move it as far as you used to. The doctor will say youâve lost range of motion.
Stage 3:
- This is the severe stage. Inflammation is wearing away cartilage and causes erosion of bones near your joints. The joints may become unstable. You might start to notice deformities as the bones move around. Youâll have pain, swelling, and loss of motion.
Stage 4:
- In end stage RA, inflammation stops, but the damage continues. The joint might stop working. Youâll still have pain, swelling, stiffness, and lack of motion. Your muscles may be weak, too. It could be time for joint replacement surgery.
What Are The Risk Factors For Ra
Researchers have studied a number of genetic and environmental factors to determine if they change persons risk of developing RA.
Characteristics that increase risk
- Age. RA can begin at any age, but the likelihood increases with age. The onset of RA is highest among adults in their sixties.
- Sex. New cases of RA are typically two-to-three times higher in women than men.
- Genetics/inherited traits. People born with specific genes are more likely to develop RA. These genes, called HLA class II genotypes, can also make your arthritis worse. The risk of RA may be highest when people with these genes are exposed to environmental factors like smoking or when a person is obese.
- Smoking. Multiple studies show that cigarette smoking increases a persons risk of developing RA and can make the disease worse.
- History of live births. Women who have never given birth may be at greater risk of developing RA.
- Early Life Exposures. Some early life exposures may increase risk of developing RA in adulthood. For example, one study found that children whose mothers smoked had double the risk of developing RA as adults. Children of lower income parents are at increased risk of developing RA as adults.
- Obesity. Being obese can increase the risk of developing RA. Studies examining the role of obesity also found that the more overweight a person was, the higher his or her risk of developing RA became.
Characteristics that can decrease risk
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Can I Cut Back On My Ra Medications If I Feel Ok
If pain and stiffness start to fade, you may wonder if you can change your medications.
RA is a long-term condition, and medicine keeps your symptoms under control. But with guidance from their doctor, some people may be able to lower the amount of medication they take.
When was your last flare?
Studies show that people who stop their RA medicine are likely to have a flare of symptoms 4 to 8 weeks later. If your disease stays active, youâre more likely to get permanent joint damage.
Your doctor will want to know how long itâs been since you had any problems. Theyâll also do some tests. If everything looks good, your doctor may slowly lower the dose of your medications, usually starting with NSAIDs.
You want to keep a constant and effective level of your RA drugs in your system, so if you are able to cut back on your medicine, it would be a slow change. It helps if you take your medicine at the same time every day.
Do you have any trouble with side effects from your meds?
If so, tell your doctor about them. They may be able to adjust your medicine. For example, many drugs used to treat RA can cause an upset stomach. To help, your doctor may suggest that take it at a different time or with food. They may also recommend medication to ease nausea and help with stomach acid.
Do you use reminders to help you take medicine on time?
Rheumatoid Arthritis Prognosis: How Soon Will Symptoms Worsen
If you’re newly diagnosed with rheumatoid arthritis , you may be wondering how severe the disease will become and what you can expect moving forward. It’s common to be curious and even anxious about your prognosis and what factors affect how quickly symptoms will get worse.
A lot of people in your position ask:
- Will I face a mild or aggressive disease course?
- Will pain become unbearable?
- Is disability inevitable?
- Will I be able to work and take care of my family?
There’s no answer to these questions that applies to everyone with RA. Your healthcare provider may be able to provide you with some sense of this, but much will only become known over time. Proper treatment can help even those with an aggressive case to retain functionality for many years.
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What Makes Ra Get Worse
Different factors affect the pace and progression of individual patients RA. Some things you cant control, like whether you have a family history of the disease. In addition, although women are more likely to get RA, when men get rheumatoid arthritis, their prognosis is generally worse, Dr. Bhatt says.
But there are factors you can control and change. We know smoking makes RA more aggressive, so smoking cessation is key, Dr. Lally says. Also, people with heavy manual occupations might stress the joints further and might have quicker progression, Dr. Bhatt says. If your workplace can make accommodations for your disease, that will help. Read more about how to make working with arthritis easier.
Exercise and maintaining a healthy weight can also help reduce stress on the joints, Dr. Bhatt says. But talk to your doctor before starting a workout regimen. A physical therapist can advise patients on the right type of exercise, he says. If patients do exercises wrong it could stress the joints even further. In addition, getting enough sleep, starting an anti-inflammatory diet, eating less red meat, and possibly using herbal remedies like turmeric may help control RA, Dr. Bhatt says. Here are more healthy habits to adopt if you have RA.
What Causes Rheumatoid Arthritis
The exact cause of rheumatoid arthritis is unknown. However, it is believed to be caused by a combination the following factors:
- Genetics
- The environment
- Hormones
Normally, the immune system protects the body from disease. In people who have rheumatoid arthritis, somethingpossibly infections, cigarette smoking, and physical or emotional stress, among other causestriggers the immune system to attack the joints .
Gender, heredity, and genes largely determine a person’s risk of developing rheumatoid arthritis. For example, women are about three times more likely than men to develop rheumatoid arthritis.
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Spotting The Early Warning Signs Of Aggressive Ra
Recent advances in drug therapies for rheumatoid arthritis have increased the importance of early intervention. Several serological testing and imaging techniques help facilitate early diagnosis. C-reactive protein level and erythrocyte sedimentation rate have limitations in predicting RA. Rheumatoid factor acts as a prognostic marker for later joint damage in patients with early RA. Antibodies against cyclic citrullinated peptide can predict more erosive disease. Radiography currently is the marker for structural damage in RA, but it cannot detect soft tissue changes or actual cartilage deterioration. MRI is the most sensitive imaging modality. Ultrasonography has been shown to be more sensitive than conventional radiography in detecting erosions.
Rheumatoid arthritis often presents late, when irreversible damage has occurred. More than half of primary care consultations are for joint pain,1 but the average time from initial presentation with symptoms to confirmation of diagnosis of RA is 18 weeks.2
Recent advances in drug therapies for RA have increased the importance of early intervention. Therefore, early diagnosis has never been more critical. Many diagnostic tests are available physicians should select them carefully in an effort to improve the time to diagnosis.
Signs Of Ra Progression And How To Slow It Down
If youre living with rheumatoid arthritis , the onset of new symptoms can come as the worst kind of surprise. When faced with new symptoms, its not uncommon to feel like youre out of control of your own health.
Even more confusing is the fact that up to 42 percent of Americans with RA experience remission periods after their initial treatments. This sometimes leads people to falsely believe that their RA can be cured. When inevitable flare-ups occur, a lot of people with RA feel disappointed.
Its true that RA is very unpredictable, but the good news is there are ways to monitor your RA and keep it in check.
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Signs Your Ra Is Progressing
How can you tell your RA is getting worse? There’s no easy way, but some general signs include:
- Flares that are intense or last a long time
- Diagnosis at a young age, which means the disease has more time to become active in your body
- Rheumatoid nodules — bumps under your skin, often around your elbows
- Active inflammation that shows up in tests of joint fluid or blood
- Damage on X-rays when you were diagnosed
- High levels of rheumatoid factor or citrulline antibody in blood tests
When To Seek Treatment
The following are general guidelines of when to seek treatment for your RA progression:
When you first suspect symptoms Regularly during the first few years of diagnosis If you suspect you are experiencing progressive rheumatoid arthritis If you feel your condition is worsening in any way or new symptoms appear
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Talk To Your Doctor About Ra Treatments
When taking meds, you should discuss a few things with your rheumatologist. For starters, tell your doctor if youre planning to start a family shortly . With some of these medications, you want to be off it for about three months before trying to get pregnant, or trying to get your partner pregnant, says Dr. Blank.
On the other hand, the DMARDs sulfasalazine and hydroxychloroquine are considered safe for pregnancy, so if youre planning to get pregnant, your doctor may start you on one of those. Theoretically, you can be on some TNF inhibitor biologic drugs until your third trimester, says Dr. Sharmeen. But the only one thats safe is Cimzia, she says.
You also want to talk about your lifestyle. For example, if you drink alcohol your doctor will avoid a drug that affects your liver enzymes. And tell your physician if you tend to get a lot of recurrent infections, upper respiratory infections, or are around young children who may pass along infectionsyour doctor may choose a less immunosuppressant drug if your situation makes you more vulnerable to infections. These are all important things for your doctor to know to find the right for you, says Dr. Sharmeen.
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How Your Ra Treatment Plan Prevents Disease Progression
Perhaps the biggest factor that affects how RA progresses is if youre in treatment with a specialist who can put you on medications to slow the disease. Being on a DMARD or biologic therapy for RA is the best way to prevent progression, Dr. Lally says.
Disease-modifying anti-rheumatic drugs are usually the first line in medication. Methotrexate is the anchor drug for rheumatoid arthritis, Dr. Bhatt says. Some patients are scared because methotrexate is also used for cancer chemotherapy so they dont want to take a chemo pill, but those we use for RA are a very small dose with lesser chance of side effects. Your doctor will reassess in a month or so and see if its necessary to add in other drugs.
If after three to six months they have still not responded then we progress to medications called biologics, Dr. Bhatt says. These genetically engineered drugs target the inflammation process specifically, and are usually self-injected or infused via IV in your doctors office or a medical center. There are sub-classes and different types, Dr. Bhatt says. Your doctor will try various medications to see which you respond best to.
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Stopping Medication Can Trigger Relapse
One reason you may have a remission relapse is simple: you stop taking your medications. When an RA patient achieves remission, some doctors will taper treatment, either by decreasing the dose of medication or increasing the time between treatments. In other cases, a doctor might decide a patient can attempt to go without any medication at all. The purpose of reducing or eliminating a patients medication is to minimize the risk of side effects that accompany todays powerful medications.
However, someone who had been in remission can have their symptoms return, explains rheumatologist Theodore Fields, MD, clinical director of the Early Arthritis Initiative in the Inflammatory Arthritis Center at New York Citys Hospital for Special Surgery. I have some patients who have been off medication for a couple of years and stayed in remission, says Dr. Fields. But thats true for only a small number of patients, hes quick to add.
Little is known about which RA patients in remission might be able to go drug-free, although some evidence hints that those who received early and aggressive treatment for the disease might be the best. However, patients who have mild symptoms, but arent in total remission, are not candidates for the cold turkey approach, stresses Dr. Field. The risk of relapse and a worsening of symptoms is too great.