Rheumatoid arthritis: management

The management of rheumatoid arthritis (RA) has been revolutionised by the introduction of disease-modifying therapies in the past decade. NICE has issued a number of technology appraisals on the newer agents and released general guidelines in 2009.

Patients with evidence of joint inflammation should start a combination of disease-modifying drugs (DMARD) as soon as possible. Other important treatment options include analgesia, physiotherapy and surgery.

Initial therapy

• in the 2009 NICE guidelines it is recommend that patients with newly diagnosed active RA start a combination of DMARDs (including methotrexate and at least one other DMARD, plus short-term glucocorticoids)

DMARDs

• methotrexate is the most widely used DMARD. Monitoring of FBC & LFTs is essential due to the risk of myelosuppression and liver cirrhosis. Other important side-effects include pneumonitis
• sulfasalazine
• leflunomide
• hydroxychloroquine

TNF-inhibitors

• the current indication for a TNF-inhibitor is an inadequate response to at least two DMARDs including methotrexate
• etanercept: recombinant human protein, acts as a decoy receptor for TNF-α, subcutaneous administration, can cause demyelination, risks include reactivation of tuberculosis
• infliximab: monoclonal antibody, binds to TNF-α and prevents it from binding with TNF receptors, intravenous administration, risks include reactivation of tuberculosis
• adalimumab: monoclonal antibody, subcutaneous administration

Rituximab

• anti-CD20 monoclonal antibody, results in B-cell depletion
• two 1g intravenous infusions are given two weeks apart
• infusion reactions are common

Abatacept

• fusion protein that modulates a key signal required for activation of T lymphocytes
• leads to decreased T-cell proliferation and cytokine production
• given as an infusion
• not currently recommend by NICE