Is Early, Aggressive Treatment Best for All Rheumatoid Arthritis Patients?

Preventing Joint Damage Is the Goal of Treatment

Many years ago, a conservative treatment approach for rheumatoid arthritis was the norm. Back then, less was more. Over the years, however, the approach has swung from conservative to aggressive. But, why the change?

The Importance of Early, Aggressive Treatment

Early diagnosis of rheumatoid arthritis is recognized as essential because early treatment with DMARDs and biologics offers the best chance to prevent joint damage, as well as lower the risk of disability and mortality associated with the disease.

The reason for this more aggressive approach is that, in the past, a significant percentage of patients with rheumatoid arthritis became disabled. Fortunately, not all patients with rheumatoid arthritis are at risk for severe joint damage and disability.

For those with mild disease, aggressive treatment may not need to be initiated. However, while NSAIDs (nonsteroidal anti-inflammatory drugs) may help the symptoms of rheumatoid arthritis, there is little to suggest that they help prevent joint damage.

Few, if any, patients with rheumatoid arthritis are candidates for treatment with NSAIDs alone. Typically, patients at low risk for joint damage are treated with older DMARD medications that are thought to have a low potential for side effects, including:

  • Plaquenil (hydroxychloroquine)
  • Azulfidine (sulfasalazine)
  • Minocin (minocycline) —An antibiotic that has shown benefit in rheumatoid arthritis, but is not FDA approved for that indication.

Medications used for moderate to severe rheumatoid arthritis include the following (with other new drugs in the pipeline):

  • Methotrexate (Rheumatrex, Trexall)
  • Arava (leflunomide)
  • Imuran (azathioprine)
  • Xeljanz (tofacitinib)
  • Enbrel (etanercept)
  • Remicade (infliximab)
  • Humira (adalimumab)
  • Simponi (golimumab)
  • Cimzia (certolizumab pegol)
  • Actemra (tocilizumab)
  • Rituxan (rituximab)
  • Orencia (abatacept)

Patients with moderate to severe rheumatoid arthritis have more problems or potential problems with activities of daily living, joint damage, and joint function. Due to potential long term use and low cost, many rheumatologists will start with methotrexate as the initial DMARD in patients presenting moderate to severe symptoms. Prednisone in low doses may also have some disease modifying benefit.

Signs and Symptoms of Joint Damage

Clinical findings that may indicate an increased risk of joint damage and subsequent disability include:

Unfortunately, it is not possible to always predict who will or will not develop joint damage. As a result, if you have signs or symptoms of rheumatoid arthritis, make sure you have a consultation with a rheumatologist to find the treatment that would be best for you.

A Window of Opportunity

There is a time frame during which rheumatoid arthritis treatment has the greatest impact on disease progression. Ideally the greatest impact would be a rheumatoid arthritis remission or at least an effect on disease progression which would be evident on x-ray or on joint function. This has been called "The Window of Opportunity" and as researchers have learned more, the window has narrowed.

The urgency behind early treatment for rheumatoid arthritis has become more clear. The most recent perspective on when aggressive treatment should be initiated is "the earlier the better."

Interestingly, trying to pin down when the window of opportunity opens and closes for an individual patient hasn't been seen as useful. But, there is no denying that bringing the disease under control as early as possible is the clear goal. That will mean treating undifferentiated arthritis, in some cases, with the hope of halting its progression to full blown rheumatoid arthritis.

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