Treatment
Early treatment is essential to suppress disease activity, reduce the risk of permanent joint damage and prevent disability. Treatment aims to achieve disease remission or low disease activity. Patients are encouraged to self-manage flare-ups. In established disease, management also focuses on addressing complications and co-morbidities.
Disease-modifying anti-rheumatic drugs (DMARDs)
These can reduce symptoms and the damaging effect of the disease on the joints. DMARDs can take weeks or months to be fully effective so patients should be encouraged to continue taking them as prescribed, even if they are not seeing an immediate benefit. DMARDs can be split into:
Conventional synthetic disease-modifying anti-rheumatic drugs (csDMARDs)
NICE recommends adults newly diagnosed with active RA are started on first-line csDMARD monotherapy with oral methotrexate, leflunomide or sulfasalazine. The dose should be escalated as tolerated. Additional csDMARDs should be offered in combination in a step-up strategy when the treatment target (remission or low disease activity) has not been achieved despite dose escalation. Bridging therapy with corticosteroids is also indicated when patients are newly started on csDMARDs to help relieve symptoms while waiting for the therapy to take effect.
Biologic disease-modifying anti-rheumatic drugs (bDMARDs)
Such as abatacept, certolizumab pegol and tocilizumab. Many originator biologics are reaching patent expiry, meaning manufacturers are now permitted to produce biosimilars. With the high number of biosimilars reaching the market, it is important that all biologic therapies are prescribed by brand name.
Targeted synthetic disease-modifying anti-rheumatic drugs (tsDMARDs)
Such as the Janus kinase (JAK) inhibitors baricitinib and tofacitinib.