Learn How to Choose the Best Treatment to Manage Arthritis

Diagnosis of rheumatoid Arthritis (RA) at an early stage is beneficial since therapies are more likely to be effective and cause less damage.


The American College of Rheumatology (ACR) and the European League Against Rheumatism (EULAR) recommend that newer biologic drugs be used with more aggressive dosing of older medications to produce the best results.

1,2 This combination tends to regulate disease activity and joint inflammation, reduce joint erosions and damage, enhance the quality of life for patients with RA, and reduce co-morbidities such as cardiovascular disease associated with chronic inflammation.

Nonetheless, therapy options might be complicated due to the numerous considerations that must be considered. In addition, patients are more likely to comply with therapy if they are involved in decision-making. Thus rheumatologists should make treatment decisions alongside them.

“Discussions should address the hazards of RA, the risks of therapy options, and the expected benefits and side effects,” says Susan M. Goodman, MD, a rheumatologist and associate director of the Inflammatory Arthritis Center of Excellence at New York’s Hospital for Special Surgery (HSS).


Vivian Bykerk, MD, rheumatologist and head of the Inflammatory Arthritis Center of Excellence at HSS, use disease parameters to predict a person’s prognosis while establishing the appropriate treatment plan. All factors to consider are the length of time the patient has had the disease, the extent of the signs and symptoms, laboratory results, imaging data, and whether or not damage has already happened. At initial diagnosis, extensive joint involvement, positive rheumatoid factor and cyclic citrullinated peptide antibodies, elevated inflammatory markers, and joint erosions are all poor prognostic indicators in RA patients.

Dr. Bykerk would also like to know if the patient has taken medication for their symptoms and their treatment goals and insurance coverage. “I’ll look into the patient’s values, their fears about the disease, and what they’ve read about treatment and risk tolerance,” Dr. Bykerk says. “Finally, we establish therapeutic objectives.”

Beginning and Evaluating Treatment

When a patient is diagnosed with RA, the ACR and EULAR guidelines recommend prescribed a disease-modifying anti-rheumatic medication (DMARD). Methotrexate is the first-line treatment of choice for most individuals with moderate to severely active RA. However, according to Monica Piecyk, MD, a 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.