Significance Of The Study
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Rheumatoid arthritis not only affects the joints but can also affect internal organs, thus causing permanent disability in many instances. Currently, there is no cure for this autoimmune disease, rather, symptoms are addressed on an individual basis. Here, we succinctly summarize the classic and current treatment options available for the management of patients suffering from this complex disease.
Ra Treatment: What Is The Safest Treatment For Rheumatoid Arthritis
Rheumatoid arthritis has no cure, but doctors recommend that patients adhere to suggested treatments early in diagnosis to decrease the severity of symptoms. There are a variety of treatment methods used to control symptoms and stop joint damage, including medications, surgery, and daily routine and lifestyle changes. Communication with a doctor or rheumatologist is necessary for choosing the most effective treatments. Your physician will ensure that treatments are safe and the medications are prescribed correctly based on each unique situation.
Treating RA will not cure the disease, but certain treatments can significantly reduce the pain and prevent permanent damage to the body. Depending on the severity of your symptoms, the goals of treatment will be to gain tight control of RA, meaning the diseases activity is kept steadily at a low level. Keeping RA in tight control can prevent long-term joint damage.
These goals primarily focus on:
- Reducing inflammation
- Preventing further or permanent damage
- Improving the quality of life
- Reducing daily and long-term side effects
Following a strict treatment regimen could bring RA into remission. Remission means that the level of disease activity has decreased in the body. It is never an indication that symptoms will not return, but following remission, many patients can go for long periods of time without experiencing symptoms.
The Significance Of Inflammation
The cytokine milieu in rheumatoid arthritis influences a multitude of physiological processes. These include promoting the influx of immune effector cells into the joint synovium, and activation of osteoclasts, chondrocytes and fibroblasts.3 There is a positive feedback loop that reinforces the inflammatory process. Unabated, this process results in joint pain and destruction, ultimately causing deformity and disability.
Chronic inflammation also contributes to an increased risk of myocardial infarction, stroke and death. A Canadian population-based prospective cohort study reported an absolute increase in cardiovascular events of 5.7 per 1000 person-years in patients with rheumatoid arthritis compared to those without.4 The use of disease-modifying antirheumatic drugs to attenuate the inflammatory process has been shown to prevent joint erosions and reduce pain, cardiovascular morbidity and mortality.3,5
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Methotrexate And Other Traditional Dmards
Disease-modifying antirheumatic drugs are used used to slow or stop rheumatoid arthritis by suppressing the immune system. The generic names for commonly used DMARDs include:
- Hydroxychloroquine
Biologic drugs target and prevent a specific reaction from happening, stopping the inflammatory process.
This class of medications, called biologic response modifiers, is technically a subset of DMARDs. They may be used with traditional DMARDs or as an alternative to them. Biologics:
- Disrupt certain parts of the cascade of events that lead to RA inflammation and have the potential to stop the disease process.
- Increase a persons risk of infection and tend to be expensive. Because of these potential downsides, biologics are used when methotrexate or other DMARDs prove insufficient or cause unacceptable side-effects.
- May become less effective and/or cause worsening side effects over time. The doctor and patient can work together to monitor changes and decide if and when switching medication is advisable.
Testing for TuberculosisBefore taking any type of biologic medication, a person must be tested for tuberculosis. People who have latent tuberculosis carry the Mycobacterium tuberculosis bacterium without having tuberculosis symptoms. If a person with latent tuberculosis takes immune-suppressing biologic medications the bacterium can multiply and cause symptomatic tuberculosis.
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What Are The Potential Risks And Benefits Of Injectable Medications For Rheumatoid Arthritis
Biologic agents used to treat RA need to be injected. The biggest benefit of these drugs is that they are very effective.
- Biologics not only relieve symptoms but also halt damage to joints and generally provide quick relief.
- The biggest drawback of biological agents is cost. Patients can spend thousands of dollars a month using biologics.
- Other drawbacks include side effects, which may be severe because biologics suppress the immune system, enhancing the possibility of infections.
- In addition, patients may not like receiving injections.
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Rheumatoid Arthritis And Diet Considerations
When it comes to the connection between diet and rheumatoid arthritis improvement, much of the scientific evidence is inconclusive, and the clinical studies haven’t been very large. But some people claim that certain dietary modifications have helped relieve their RA symptoms. It’s important to check with your doctor before you make any significant changes to your dietary habits.
Nutrition ReviewsAnnals of the Rheumatic DiseasesFrontiers in Nutrition
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
Combination therapy
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What Are The Goals Of Treating Rheumatoid Arthritis
The most important goal of treating rheumatoid arthritis is to reduce joint pain and swelling and to maintain and/or improve joint function.
The long-term goal of treatment is to slow or stop the disease process, particularly joint damage, which can be seen on X-rays. Once joint inflammation is controlled, pain will be reduced.
Normal joint and joint affected by rheumatoid arthritis
In the past, many doctors did not believe that drugs for rheumatoid arthritis changed the likelihood of eventual disability from the disease. Therefore, drugs with the fewest side effects were prescribed to decrease pain. Stronger drugs were avoided because of doctors concerns about dangerous side effects.
Now, however, doctors know that early treatment with certain drugs can improve the long-term outcome for most rheumatoid arthritis patients. Numerous drugs that have been shown to be effective are being used soon after the patient is diagnosed. Combinations of drugs are proving to be more effective than a single drug therapy and, in recent studies, have been found to be just as safe as single-drug treatment.
How Do I Take Methotrexate
Methotrexate is typically taken once a week for RA. It is available as both a tablet you take by mouth and as an injection. With the tablets, most people start with one 7.5 mg dose once a week, but your provider may recommend up to a maximum dose of 25 mg once a week depending on how you respond. To reduce the risk of side effects, they may ask you to split the dose into smaller doses that you take throughout the day of the week youre scheduled to take your medication.
If youre using the injection, thats once a week, too. Youll inject the medication either into your muscle or right under your skin, depending on what your provider recommends. The injection is available as either an auto-injector or as a vial. You can find instructions on how to use Rasuvo from the manufacturer here.
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Controlling Ra Symptom Flare
Even with regular treatment, you may occasionally experience flare-ups periods of increased disease activity that causes spikes in symptoms.
Mild flare-ups can sometimes be treated at home with NSAIDs, rest, hot or cold compresses, or gentle exercise. If these treatments dont work, your doctor may prescribe oral corticosteroids, which will help reduce the inflammation causing your symptoms, and possibly alter any conventional or biologic DMARDs you may be taking.
Importantly, its best to try to treat your flare-up rather than take the wait-and-see approach to prevent further joint damage.
Other Immunomodulatory And Cytotoxic Agents
Some additional immunomodulatory drugs are used in RA including azathioprine , and cyclosporin A . Rarely cyclophosphamide and d-Penicillamine are used. Because the potential of high toxicity, these agents are typically utilized for life-threatening extra-articular manifestations of RA such as systemic vasculitis or with severe articular disease that is refractory to other therapy.
Azathioprine has some activity in rheumatoid arthritis but may take 8-12 weeks to see an effect. It is a purine analog that can cause bone marrow suppression and lowering of blood cell counts particularly in patients with renal insufficiency or when used concomitantly with allopurinol or ACE inhibitors. Increased risk of secondary malignancy due to azathioprine is controversial. Screening for levels of the enzyme thiopurine methyltransferase is recommended before initiating therapy with azathioprine. Certain individuals have deficiencies in this enzyme that metabolizes azathioprine with a concomitantly increased risk of toxicitiy for the medication. Side effects include nausea, and alopecia. Blood tests to monitor blood counts and liver function tests are necessary for patients on azathioprine.
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What Are Effective Over
Most patients with Rheumatoid Arthritis will, at some point, use over-the-counter medications to control pain — most commonly, acetaminophen . Other OTC medications which can help with RA pain and inflammation include aspirin and non-prescription versions of ibuprofen or naproxen . In addition, some topical pain medications may also provide relief. These ointments and creams are generally divided into three categories:
Salicylates
Salicylates are derivatives of aspirin. In topical form, they are absorbed through the skin and exert a local, anti-inflammatory effect.
- Aspercreme
- Omega-3-fatty acids, found in fish oil capsules, may reduce inflammation.
- The same would be true for gamma-linoleic acid. Herbal preparations with possible benefits include ginger, Devil’s claw, and white willow.
What Is A Generic Drug
Generic drugs are the same medicine as the brand name but will cost less. Generics will have the same “dosage form, safety, strength, route of administration, quality, performance characteristics, and intended use. This means you can take the generic drug and still get the same benefits and effects as the brand-name drug.
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Before Taking This Medicine
You should not use methotrexate if you are allergic to it. You may not be able to take this medicine if you have:
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alcoholism, cirrhosis, or chronic liver disease
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low blood cell counts
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a weak immune system or bone marrow disorder or
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if you are pregnant or breastfeeding.
Methotrexate is sometimes used to treat cancer in people who have a condition listed above. Your doctor will decide if this treatment is right for you.
To make sure this medicine is safe for you, tell your doctor if you have ever had:
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liver problems, especially fluid in your stomach
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kidney disease
Tell your doctor if you are pregnant or plan to become pregnant. Methotrexate may cause injury or death to an unborn baby and should not be used during pregnancy to treat arthritis or psoriasis. However, methotrexate is sometimes used to treat cancer during pregnancy.
Methotrexate can harm an unborn baby if the mother or the father is using this medicine.
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If you are a woman, you may need to have a negative pregnancy test before starting this treatment. Use effective birth control to prevent pregnancy while you are using methotrexate and for at least 6 months after your last dose.
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If you are a man, use effective birth control if your sex partner is able to get pregnant. Keep using birth control for at least 3 months after your last dose.
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Tell your doctor right away if a pregnancy occurs while either the mother or the father is using methotrexate.
Comparisons Across Treatment Strata
Some baseline differences were observed across treatment groups . As expected, a history of adverse events requiring medication change was more frequent in the groups other than the first csDMARD. In terms of clinical factors, there was no variability across the groups, except for the RAID score, which was also lower in this first group in comparison to the other more experienced ones, although the DAS-28 showed no statistical differences.
Interestingly, while rheumatologists did not think they had explained better or worse depending on the groups, the patient perception of the adequacy of information was better in terms of practical aspects and adaptation to needs in the group with bDMARD/tsDMARD than in the others.
For psychological factors, patients from the bDMARD/tsDMARD had a perception of need higher than the other groups .
No other differences were found in the rest of the treatment-related, patientdoctor relationship-related or psychological factors across groups.
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What Rheumatoid Arthritis Medications Are In Development
Rheumatoid arthritis treatment is an active area of research. In fact, according to the Pharmaceutical Research and Manufacturers of America, more than 50 drugs for rheumatoid arthritis are in various stages of clinical testing. Many of these are new biologics. Others target histamine receptors and glucocorticoid receptors.
Tumor Necrosis Factor Inhibitors
Tumor necrosis factor alpha is a pro-inflammatory cytokine produced by macrophages and lymphocytes. It is found in large quantities in the rheumatoid joint and is produced locally in the joint by synovial macrophages and lymphocytes infiltrating the joint synovium. TNF is one of the critical cytokines that mediate joint damage and destruction due to its activities on many cells in the joint as well as effects on other organs and body systems. TNF antagonists were the first of the biological DMARDS to be approved for the treatment of RA. These drugs began to enter the market for rheumatoid arthritis in 1999 and are now considered a part the ACR recommendations for treatment of RA. There are currently five TNF inhibitors FDA approved for the treatment of RA etanercept , infliximab , adalimumab , certolizumab pegol , and golimumab . Etanercept is a soluble TNF receptor-Fc immunoglobulin fusion construct infliximab, adalimumab, and golimumab are monoclonal antibodies and certolizumab pegol is an anti-TNF antigen binding domain-polyethylene glycol construct. While differing in structure, the efficacy and safety of the drugs is similar across the class in reducing the signs and symptoms of RA, as well as in slowing or halting radiographic damage, when used either as monotherapy or in combination with methotrexate.
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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, you’re more likely to get permanent joint damage.
Your doctor will want to know how long it’s 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?
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