In a previous blog post, I talked about Rheumatoid Arthritis And Its Causes, Symptoms, and Diagnosis. In this post, however, I discuss the best treatment options for rheumatoid arthritis. And what is “best” (according to my research) depends on the specific results the patient hopes to achieve. Is the goal to relieve the symptoms? Slow down or stop the disease progression and prevent joint or organ damage? The options are explored here.
There have been many changes made in the treatment of rheumatoid arthritis over the past 20 years and more changes are expected. It used to be that a physician would suggest an over-the-counter drug, prescribe medication, or give the patient a corticosteroid shot. Then they would watch and wait until the RA got worse.
In other words, the course of action was to treat the symptoms rather than the disease itself.
Today, a rheumatologist would prescribe a strong medication right away to stop the disease before major damage occurs.
According to the Arthritis Foundation, the main goals of treatment for rheumatoid arthritis (RA) are to:
Stop or reduce the inflammation (bring it to remission) as early as possible
Prevent joint and organ damage
Improve overall well-being and physical function
Decrease any long-term complications
According to John Hopkins Arthritis Center, there is no known cure for rheumatoid arthritis. However, in the past few years, new classes of medications have become available that improve the outcomes in most patients with RA.
Types of Rheumatoid Arthritis Treatment
The types of treatment usually include medication, joint stress reduction, physical and occupational therapy, and surgery. Although surgery is not performed as often as it once was due to early and aggressive treatment, it may be needed to correct any joint damage.
Different medications are prescribed for the treatment of RA based on the targeted goal. Some medications relieve the symptoms, while others slow or stop the progression of the disease and prevent joint and organ damage.
Drugs For Symptom Relief
Nonsteroidal anti-inflammatory drugs (NSAIDs) help with the pain and inflammation and include drugs such as ibuprofen, ketoprofen, and naproxen. A prescription will provide a higher dose than what is available over the counter, and the results last longer, as reported by WebMD.
Celecoxib, a type of NSAID, called a COX-2 inhibitor, may be prescribed for patients with stomach concerns and is taken orally or as a patch or cream directly to the swollen joint.
Drugs that Slow or Stop Disease Activity
Includes such drugs as prednisone, prednisolone, and methylprednisone to control the potentially damaging inflammation and may be taken orally or by injection into the affected joint.
May be taken to get the potentially damaging inflammation under control while waiting for NSAIDs or DMARDs to take effect. However, corticosteroids may only be taken short term and in small doses due to their potential side effects.
DMARDs (disease-modifying antirheumatic drugs)
Used to change the course of the disease, traditional DMARDs include such medications as methotrexate, hydroxychloroquine, sulfasalazine, leflunomide, cyclophosphamide, and azathioprine.
These medications can be provided in the physician’s office as an infusion, or the patient may take it orally or inject it at home.
A subset of DMARDs, biologics often work more quickly than the traditional DMARDs. They can slow down, stop, or change the progression of the disease when other treatments are unable to and are provided in a physician’s office by injection or infusion.
Since their objective is to target particular steps in the inflammatory process, they are able to avoid destruction of the entire immune system as some other RA treatments do.
This new subcategory of DMARDs blocks the Janus kinase (JAK) pathways which are part of the body’s immune response. Rather than a biologic, these are small molecules.
Tofacitinib and baricitinib are both in this class of drugs and can be taken by mouth.
Biologics and Other DMARDs – First Line of Treatment
Biologics and other disease-modifying antirheumatic drugs (DMARDs) have changed how RA is treated, according to WebMD. Painkillers, steroids, and multiple surgeries are no longer the recommended treatment of choice.
Instead, a rheumatologist will begin with a DMARD at the time of diagnosis, and methotrexate is often the drug provided. If the methotrexate or other DMARD is not doing a good enough job, the rheumatologist may turn to biologic therapy or recommend a combination of methotrexate and a biologic, such as abatacept (Orencia). Using abatacept in combination with methotrexate may be more effective, according to the American College of Rheumatology, However, abatacept should not be used with other biologic drugs.
Other reasons to switch from a DMARD to a biologic may be the patient is pregnant or may become pregnant, or the patient is experiencing side effects from the DMARD, such as liver problems. In these cases, biologics are safer.
The quicker the treatment is started, the sooner the patient’s joint damage can slow down or put the disease into remission. This results in less pain and stiffness. And by using biologics and other DMARDs, surgeries that were once considered routine can be avoided, and the outcome is much better.
Side Effects of Biologics and Other DMARDs
The purpose of biologics and other DMARDs are to block attacks from the immune system and target specific steps in the inflammatory process. However, both traditional DMARDs and biologics increase the chances of infections, such as pneumonia. Other potential side effects, although rare, are based on the particular DMARD or biologic prescribed and include:
Skin irritation at the site of injection
Increased risk of infection, such as tuberculosis
Increased risk of particular cancers
Increased risk of heart and neurologic problems
If the patient has a condition such as multiple sclerosis, hepatitis, or heart failure, a biologic may not be advised.
Fortunately, not everyone with RA requires surgery. However, it may be something to consider if the RA causes permanent damage that hinders a person’s daily function, mobility, and independence. The patient should talk to the primary physician, rheumatologist, and an orthopedist to determine the best surgical procedure based on the individual’s goals, rehabilitation ability, and overall medical status.
Types of Joint Surgeries
Joint surgeries are common in the hips and knees and are also performed on other joints, such as the ankles, shoulders, wrists, and elbows. There are eight types of joint surgeries performed, but according to Arthritis-Health, the most common types performed in patients with rheumatoid arthritis are joint replacement, arthrodesis, and synovectomy.
Total Joint Replacement (TJR), also known as Total Joint Arthroplasty. The damaged joint is removed, and an implant made from combinations of metal, plastic, and/or ceramic parts is inserted in its place. This implant mimics the movement of the natural joint.
Minimally Invasive TJR. Similar to the traditional TJR in that it replaces a damaged joint, but shorter incisions are made and less muscle is cut and reattached.
Arthrodesis, also known as Fusion. To connect two or more bones in the ankles, wrists, thumbs, fingers or spine, surgeons form one uninterrupted joint by using pins, plates, rods or other hardware. This allows the bones to grow together and lock the joint in place.
Synovectomy. The synovium, or lining of the joints, can become inflamed or grow too much in people with inflammatory arthritis. This damages surrounding cartilage and joints. Surgeons perform open or arthroscopic surgery to remove most or all of the affected synovium.
Other types of joint procedures include:
Arthroscopy. Small incisions, specialized instruments, and a tiny camera are used to fix tears in the soft tissues surrounding the knee, hip, shoulder, and other joints; damaged cartilage is repaired; and broken, detached cartilage pieces are removed.
Joint resurfacing. When the knee is involved, it may also be referred to as unicompartmental or partial knee replacement. Surgeons replace just one of the three compartments of the knee with an implant. These include the medial (inside), lateral (outside) or patellofemoral (front) compartment. When the hip is involved, surgeons take the hip socket out and put in place a metal cup before reshaping the hip ball and covering it with a metal, rounded prosthesis.
Osteotomy. Near a damaged joint, a bone is cut or removed, or a wedge of bone is added. For example, in the knee, this procedure takes the weight off the arthritis-damaged area and places it on the undamaged area. An osteotomy of the hip is often performed to correct hip dysplasia that happens early in life.
- Joint Revision. An implant that has failed, become worn, or infected, is surgically replaced with a new implant.
What may begin as mild inflammation will only get worse if left untreated. Therefore, it is not recommended that patients let the damage get so severe that even surgery cannot improve the disease. Besides deformity, loss of function, and painful joints that lead to destruction, other manifestations can occur. Untreated RA can also lead to premature death. Even though there is no cure for rheumatoid arthritis, biologics and other DMARDs are more successful than anything previously available.
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