Management of Early Rheumatoid Arthritis

(Management of Early Rheumatoid Arthritis: E Suresh, Journal of the Association of Physicians of India JAPI, Volume 55, May 2007)

Q. What has been the ideological shift in management of Early Rhematoid Arthritis ?

In the earlier time the philosophy was “Go Slow, Go low” which means drugs were added in a pyramidal system, NSAIDS followed by DMARDS followed by Steroids. Now the idea is to start treating Rheumatoid Arthritis aggressively by starting DMARDs early. This is because it has been found that irreversible damage occurs to the joints once the window of opportunity in treatment in early Rheumatoid arthritis is lost when the inflammation is still active.

Q. What is the role of Cyclic Citrullinated Peptide (CCP) in early diagnosis of RA ?

CCP is an early marker of RA. Its prevalence in blood precedes symptoms of RA by years !

Q. How will you manage a patient with Early Undifferentiated Inflammatory Arthritis ?

Since the American Rheumatology Guidelines suggest that the symptoms must persist for 12 wk for diagnosis of RA, hence we cannot accurately diagnose a person to have Rheumatoid arthritis before that period passes. And yet like mentioned before, the window of opportunity presents early, hence to resolve this conflict trials are underway to Stop RA Very Early or SAVE trial.

According to the article if a patient presents with Rheumatoid like Polyarthritis early :

If multiple joints are involved give 120 mg of Methyl Prednisolone deep IM
If fewer joints are involved Intrarticular steroids are useful.

If Remission is not achieved for 12 wks patient is classified as having RA and started on DMARDs.

Q. Which are the best DMARDs to start with ?

Methotrexate, Sulphasalazine and Leflunomide are suggested as first line agents for monotherapy by the article.

Practical Pearl : Patients on Methotrexate should be discouraged to take alcohol.

Q. Are DMARDs safe in Pregnency ?

Methotrexate and Leflunomaide are proven teratogens. They are absolutely contraindicated in pregnancy. Patients should be off methotrexate for 3 months before they conceive. Cholestyramine or activated charcoal should be used for patients on Leflunomide to wash it off .

Sulphasalazine is relatively safe in pregnancy, though higher dose of folic acid should be prescribed.

Q. What is DAS score ?

DAS score or Disease activity score is an important parameter for monitoring prognosis of patients of RA. (See http://www.dasscore.nl/ for details. )

Score >5.1 suggests high disease activity

Q. What is the role of Infliximab ?

Infliximab is an Anti-TNF agent. It has been proven to be effective in RA. If given it is combined with Methotrexate. It gives remission of upto one year on stopping therapy. The article suggests that currently the use of Infliximab is limited to research settings due to its high cost.


Important Notice: It has been proven that COX-2 inhibitors (Coxibs) increase risk of MI, Stroke and Thrombosis

Q. What is most important contraindicated to intrarticular steroid injection ?

Septic Arthritis is an important C/I to Intraarticular steroid injection.

While injecting IA steroids care should be taken not to inject > 3 joints in one sitting and same joint not more than 3-4 times a year.

Q. Does Alternative medicine help in RA ?

Gamma linoleic acid, an important component of Ayurvedic drugs for RA is found useful in RA. Mediterranean diet, Vegetarian diet , Fish oil supplementation and Yoga are other alternative therapies found useful.

Q. What is the most important cause of death in patients with RA ?

Accelerated Atherosclerosis.