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, healthcare providers 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, healthcare providers 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 healthcare providers 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.

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:

• Plaquenil (hydroxychloroquine)
• Azulfidine (sulfasalazine)
• Minocin (minocycline, an antibiotic that has shown benefit in RA but is not approved for this use)

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 healthcare providers prescribe for RA. If you don't tolerate them or they're not improving your condition enough, your practitioner may switch you to a biologic or JAK inhibitor, or they may keep you on the DMARD and add other medications.

Common DMARDs include:

• Rheumatrex, Trexall (methotrexate)
• Arava (leflunomide)
• Imuran (azathioprine)

Glucocorticoids are sometimes prescribed to help alleviate pain and inflammation while a DMARD takes time to start working. The American College of Rheumatology’s 2021 guidelines recommend using the lowest effective dose for the shortest duration possible and discourage more than three months of glucocorticoid use when starting a conventional DMARD.

Biologics

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

• Enbrel (etanercept)
• Humira (adalimumab)
• Simponi (golimumab)
• Cimzia (certolizumab pegol)
• Actemra (tocilizumab)
• Orencia (abatacept)
• Remicade (infliximab)
• Rituxan (rituximab)

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:

• Xeljanz (tofacitinib)
• Olumiant (baricitinib)
• Jakafi (ruxolitinib)
• Rinvoq (upadacitinib)

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 healthcare provider 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:

• Joint swelling
• Prolonged morning stiffness
• Onset of rheumatoid arthritis at a younger age
• Very high CCP antibody
• Very high rheumatoid factor
• Rheumatoid nodules
• Elevated C-reactive protein (CRP) and sedimentation rate
• Abnormalities on X-rays

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

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.