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Early intervention in rheumatoid arthritis pays off

Early intervention in rheumatoid arthritis pays off

ABSTRACT: The outlook for patients with newly diagnosed rheumatoid arthritis (RA) has improved greatly, but many questions remain, including when to initiate therapy and what drugs to use. Recently issued recommendations for managing early RA include referring patients who present with arthritis of more than 1 joint to a rheumatologist. Combination's of drugs have been shown to be more effective than monotherapy. The tumor necrosis factor α inhibitors have revolutionized treatment, and other biologic agents are available for those who have an inadequate response. Making the diagnosis early often presents a challenge. Recently, a prediction rule was published for patients with undifferentiated arthritis of recent onset. The imaging focus for early arthritis has shifted from radiographs to ultrasonography and MRI. (J Musculoskel Med. 2008;25:70-76)

 

In the past, the diagnosis of rheumatoid arthritis (RA) often foretold a future of joint damage resulting in a patient’s loss of function and inability to participate in the workforce,1 decreased life expectancy, and increased health care costs.2 However, the outlook for patients with newly diagnosed RA has improved greatly over the past 20 years.3 The advent of earlier treatment, the use of disease-modifying antirheumatic drugs (DMARDs) in combination, and the use of biologic response modifiers have been shown to slow the progression of radiographic joint damage and maintain or improve physical function in patients who present with RA.4

Current patients with RA are less likely than patients in 1985 to have significant work disability, decreased physical function, and premature mortality.3 However, many questions remain about when to initiate therapy, what combination of drugs to use, how to monitor disease activity, and when to adjust therapy. In this article, I attempt to provide some useful answers.

Clarifying early arthritis

What is early arthritis? How is it different from RA that fulfills the American College of Rheumatology (ACR) criteria? How should it be managed and measured? In a recent report, a select European League Against Rheumatism (EULAR) committee took on the daunting task of answering these questions. From their hard work arose a welcomed clarity about the complicated and evolving area of early arthritis.

The study used a standard EULAR approach of asking 14 rheumatology experts from 10 European countries to generate matters of interest about the management of early arthritis. From this process arose 12 management recommendations.

This clinical road map to early arthritis, supported by proper legends and mileposts, was the first of its kind. Early management of RA has become a mantra, but how to address the earliest stirrings of joint inflammation that can resolve or evolve into RA has heretofore involved extrapolating from lessons learned with RA.1,2

A fitting first recommendation was that patients presenting with arthritis of more than 1 joint should be referred to and seen by a rheumatologist, ideally within 6 weeks after the onset of symptoms. Recommendations also included the following:

The clinical examination is the method of choice for detecting arthritis (ultrasonography, MRI, or power Doppler may be used in difficult cases).
Some screening laboratory tests (eg, antinuclear antibodies) are needed for exclusion of other disorders, such as systemic lupus erythematosus.
Factors that predict persistent or erosive disease (eg, anti-cyclic citrullinated peptide [anti-CCP], rheumatoid factor [RF]) should be measured, and patients at risk for persistent or severe RA need to be treated immediately and with NSAIDs, short courses of corticosteroids or intra-articular corticosteroids, and the anchor drug methotrexate (MTX), aiming for remission.

In spite of cardiovascular, GI, and other concerns about NSAIDs and cyclooxygenase 2 selective inhibitors, most physicians in my division of 44 rheumatologists still include an NSAID in the regimen and add a proton pump inhibitor or, if needed, low-dose aspirin. As always, the physician in partnership with an informed patient must make cost-benefit decisions about all medications, including NSAIDs.

Monitoring of disease activity (using tender/swollen joint counts, patient and physician global assessments,  C-reactive protein level [CRP], erythrocyte sedimentation rate [ESR], the Health Assessment Questionnaire [HAQ], or the Disease Activity Score [DAS]) is mandatory every 1 to 3 months; in addition, joint damage assessment using plain x-ray films every 6 to 12 months is needed.
Treatment adjuncts (eg, dynamic exercises) may be applied along with pharmacological measures.

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