Starting & Evaluating Treatment
When a patient is diagnosed with RA, the ACR and EULAR guidelines recommend that a disease-modifying anti-rheumatic medication (DMARD) be prescribed. Methotrexate is the first-line treatment of choice for most individuals with moderate to severely active RA. However, according to Monica Piecyk, MD, rheumatologist at New England Baptist Hospital in Boston, most insurance companies require a patient to have had a poor response to methotrexate before beginning a biologic.
When methotrexate is contraindicated, such as an impending pregnancy or a history of liver disease, Dr. Goodman suggests another synthetic DMARD, such as leflunomide (Arava), or tumor necrosis factor (TNF) inhibitors, maybe a possibility.
Hydroxychloroquine or sulfasalazine may be beneficial in people with low disease activity. Because DMARDs might take months to become fully effective, Dr. Piecyk recommends prescription NSAIDs or short-term prednisone to patients who cannot perform specific daily activities, as this may provide more immediate pain and stiffness relief.
Corticosteroids are a short-term temporary medication used to bridge between therapies or to reduce flares until long-term medicines take effect. Patients are frequently concerned about side effects such as weight gain, inability to sleep, the beginning of diabetes, or poor glucose control. Dr. Goodman recommends monitoring a patient’s response to therapy and making changes to the dose, mode of administration, or medication during the first one to three months of treatment. This necessitates regular follow-up evaluations.
“I am more likely to add a second DMARD or a biologic to patients with poor prognostic indicators after three months on methotrexate,” Dr. Piecyk explains.
Also, keep in mind that smoking and anti-citrullinated protein antibody positivity are known prognostic indicators of poorer outcomes.
A Closer Look at DMARDs
Methotrexate, through modifying the immune system, alleviates every day RA symptoms and minimizes the risk of long-term joint damage. The recommended weekly dose is 20–25 mg. In early RA, methotrexate monotherapy achieves remission 30–40% of the time.