Treatment of Rheumatoid Arthritis Part 2

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Management Rheumatoid arthritis

Both nonpharmacological and pharmacological modalities should be utilized to manage rheumatoid arthritis, including surgery, if indicated. Although there is presently no cure for rheumatoid arthritis, the goals of therapy are to control disease activity; alleviate pain; maintain function for essential activities of daily living and work; maximize quality of life; slow the rate of joint damage; and, if possible, induce complete remission.

Nonpharmacologic: Nonpharmacologic therapy is an important component of managing rheumatoid arthritis. These modalities help patients to manage their own disease and maintain their quality of life. Patient and family education should focus on the pathology and course of the disease; options for drug and nondrug therapy; potential drug interactions and side effects; and monitoring the progression of the disease. Physical therapy is important to preserve and maintain range of motion of joints and prevent muscle atrophy. Adequate rest will help decrease systemic inflammatory responses, protect the joints, and permit repair. The key is to maintain balance between proper rest and physical activity. To minimize joint instability and maintain strength, individualized exercise programs should be designed to move joints through their full range of motion. Occupational therapy teaches patients how to manage activities of daily living (ADLs) and properly use supportive devices such as canes or splints, which may become necessary as the disease advances. Support services such as the Arthritis Foundation and local patient support groups can significantly benefit patients and their families.

Pharmacologic: Agents available to manage rheumatoid arthritis continue to increase in number. Historically, the pharmacologic approach to managing rheumatoid arthritis was represented as a pyramid. Therapy was initiated with salicylates or nonsteroidal anti-inflammatory drugs (NSAIDs). When this therapy was no longer effective in providing symptom control, patients would move to the next level — disease-modifying anti-rheumatic drugs (DMARDs). DMARDs may help to slow progression of the disease or induce remission. If DMARDs do not achieve desired results or the patient develops toxicity, options are limited and patients often are placed on combination therapy or experimental protocols.
The pyramid was designed to start patients on what was believed to be the least toxic medication during the early stages of the disease. As the disease progressed, more toxic medications were used. While NSAIDs are at the bottom of the pyramid, such side effects as GI ulcerations and changes in kidney function can be problematic, especially in the elderly. It has been recently recognized that joint and bone erosion can develop after only a couple of months of experiencing rheumatoid arthritis symptoms; therefore, the pyramid approach has been largely abandoned in favor of more aggressive therapy given early in the disease.
Wilske and Healey proposed a “step-down bridge” alternative to the pyramid for the treatment of rheumatoid arthritis. They suggested that combinations of drugs given early in the disease may induce remission and prevent joint destruction. Patients were started with a fast-acting anti-inflammatory (corticosteroid). If symptoms persisted after one month, a DMARD was added to the regimen. After three months, the patient was tapered off the steroid and continued on the DMARD. In order to control acute flare-ups, patients were given methotrexate and, as needed, steroids. A variation on this treatment strategy, the “sawtooth approach,” utilizes combinations of DMARDs and substitutes new agents if benefit from the original agents is lost. Patients are then gradually tapered off the various medications, leaving them on a single DMARD. Critics of the “step-down bridge” approach state that it unnecessarily exposes patients to toxic medications. Since it is not possible to determine which patients will develop aggressive disease, exposing all patients to combination therapy adds additional costs for drugs and monitoring. The risk–benefit ratio for combination therapy is still being evaluated. Some patients displaying less than optimal response may benefit from the use of combinations of DMARDs.

Over-the-counter (OTC) salicylates and NSAIDs include aspirin, ibuprofen, magnesium salicylate, naproxen, and ketoprofen (Table 1). The anti-inflammatory response desired in rheumatoid arthritis is achieved at higher doses than those recommended on the OTC product labeling.