Is Early, Aggressive Treatment Best for All RA Patients?

Many years ago, a conservative treatment approach for rheumatoid arthritis (RA) was the norm. Over the years, however, doctors switched to favoring an early and aggressive one as it became more and more apparent that the sooner RA treatment starts, the better the long-term outcomes.

This altered approach has improved the outcomes and life expectancies of people with this disease. In fact, studies show that modern treatments, given early on, prevent irreversible joint damage in up to 90% of people with RA.

Window of Opportunity

Multiple studies show that RA treatment has the greatest impact on disease progression when it's started within a specific time frame—a period often referred to as "the window of opportunity."

In the 1990s, doctors believed the optimal window to start treatment with biologics was within the first two years after diagnosis. Now, conventional medical wisdom is that it's better to start even earlier whenever possible. This includes adopting an aggressive approach for undifferentiated arthritis—a diagnosis that often precedes an RA diagnosis—with the hope of preventing its progression to full-blown RA.

Starting treatment then can give you your best shot at rheumatoid arthritis remission or at least slower disease progression and better long-term joint function. The more researchers have studied this phenomenon, the more they've narrowed the window on the optimal time frame.

Impact of an Aggressive Approach

In the past, a significant percentage of people with RA became disabled, so doctors wanted to find ways to improve the prognosis and keep people more functional.

Research and clinical evidence has shown that early diagnosis and treatment with disease-modifying anti-rheumatic drugs (DMARDs) and/or biologics offers the best chance of preventing permanent joint damage later on. These medications also lower your risk of disability and mortality associated with the disease.

According to research published in 2018, each person with RA has a 15% increased chance of dying early due to the disease, its complications, or those related to treatment. That number dropped significantly after 2006, likely due to improved treatment options.

Prescription Drug Options

Typically, if you're at low risk for joint damage from RA, you'll be treated with older DMARD medications that are thought to have a low potential for side effects, including:

Medications used for moderate-to-severe rheumatoid arthritis come from several drug classes, and new drugs are always in the pipeline.

DMARDs

DMARDs are most often the first drug doctors prescribe for RA. If you don't tolerate them or they're not improving your condition enough, your doctor may switch you to a biologic or JAK inhibitor, or they may keep you on the DMARD and add other medications.

Common DMARDs include:

Methotrexate has been around for a long time and is relatively inexpensive, so it's often the drug doctors start with.

Biologics

Biologic drugs are derived from living cells. Several biologics on the market are:

JAK Inhibitors

JAK inhibitors block the action of Janus kinase enzymes, which are involved in the autoimmune response and inflammation seen in RA. This is a new and growing drug class that includes medications such as:

The corticosteroid prednisone, in low doses, may also have some disease-modifying benefit.

Signs Your Treatment Plan May Need a Change

When rheumatoid arthritis isn't properly treated, it can lead to permanent joint damage and disability.

You and your doctor should keep an eye out for signs and symptoms of joint damage. Identifying them early can help you reevaluate your treatment plan before the damage worsens.

These include:

It's not always possible to predict who will develop joint damage.

What About Juvenile RA?

Adult RA and juvenile RA are similar but different enough that the childhood form is now most often called juvenile idiopathic arthritis (JIA).

A "window of opportunity" for preventing early JIA from becoming chronic may exist, possibly within the first two years of symptom onset. However, researchers are still trying to confirm this window and, if it does exist, which cases would likely benefit from early, aggressive treatment.

A Word From Verywell

If you got a quick RA diagnosis and are able to start aggressive treatment soon, the prognosis has never been better. Unfortunately for some, RA diagnosis can take time, and aggressive treatments may need to be delayed for various other health reasons.

If this sounds like you and you've missed the window of opportunity described here, know that proper medical guidance and an ever-increasing number of drug options may still be able to reduce your symptoms and improve your quality of life. It may even halt disease progression or support remission.

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