Treatment: Rheumatoid Arthritis

Goals: lessen pain, reduce inflammation, improve/maintain function, prevent long-term joint damage, control of systemic involvement. Increasing trend to treat RA more aggressively earlier in disease course (Table 380-2, HPIM-19, pp. 2146-2147). All RA therapies have individual toxicities, with many requiring pretreatment screening and monitoring.

• Pt education on disease, joint protection.
• Physical and occupational therapy: strengthen periarticular muscles, consider assistive devices.
• Aspirin or NSAIDs.
• Intra-articular glucocorticoids.
• Systemic glucocorticoids.
• Disease-modifying antirheumatic drugs (DMARDs): e.g., methotrexate, hydroxychloroquine, sulfasalazine, leflunomide.
• Biologic therapies.
• TNF-modulatory agents (etanercept, infliximab, adalimumab, golimumab, certolizumab): effective at controlling RA in many pts and can slow the rate of progression of radiographic joint damage and decrease disability; carry potential for serious infection and individual toxicities.
• Abatacept (CTLA4-Ig): inhibits T-cell activation, can be given with or without methotrexate.
• Rituximab: a chimeric antibody directed to CD20 that depletes mature B cells and is approved for refractory RA.
• Tocilizumab: humanized monoclonal antibody directed against the IL-6 receptor.
• Tofacitinib: oral small molecule inhibitor that primarily inhibits JAK1 and JAK3.
• Anakinra: an IL-1 receptor antagonist approved for RA but rarely used in RA due to only modest clinical efficacy.
• Surgery: may be considered for severe functional impairment due to deformity.