The modern and sensible approach to the treatment of rheumatoid arthritis

The modern and sensible approach to the treatment of rheumatoid arthritis

Rheumatoid arthritis is the most common inflammatory form of arthritis. It affects about 2.1 million Americans. Here is the management approach we use at the Arthritis and Osteoporosis Center of Maryland.

o Make the diagnosis:

This means listening: We ask questions like: How much stiffness do you have in the morning? How long does it take? How long have you had your symptoms? How tired are you? Do you have painful joints? Any swollen joints? Is there a family history of rheumatoid arthritis?

That means looking: Is there joint swelling? Which joints? Is the pattern symmetrical (one side looks like the other)? Any joint redness? Any other associated symptoms such as dry eyes and mouth (which may indicate Sjögren's syndrome, a condition often associated with rheumatoid arthritis)?

This means you will receive the appropriate tests:

Blood tests: Rheumatoid factor, antinuclear antibody, anti CCP, erythrocyte sedimentation rate (Sedrate), C-reactive protein, complete blood count, blood chemistry, thyroid function, urinalysis.

Imaging: Magnetic resonance imaging (MRI) or ultrasound for early detection of inflammation and erosions (damage). Damage to the joints occurs within six months of occurrence!

o Begin aggressive treatment:

Rheumatoid arthritis is the result of a self-perpetuating immune system dysfunction that leads to overproduction of harmful chemical messengers called cytokines and chemokines. These harmful messenger substances lead to the excessive formation of destructive enzymes. The damage caused by these different enzymes affects many organ systems such as the joints, lungs, eyes and heart. In addition, the chronic inflammation causes further complications such as accelerated atherosclerosis (hardening of the arteries), which leads to early heart attack and stroke. Another possible complication is the development of lymphoma (cancer of the lymphatic system).

A diagnosis of rheumatoid arthritis is therefore considered a medical emergency and must be treated as such. This refers to disease-modifying anti-rheumatic drugs (DMARDS). These medications slow the progression of the disease. We most often use methotrexate. We also add low-dose prednisone or perhaps a nonsteroidal anti-inflammatory drug (NSAID) to relieve symptoms.

If a patient doesn't improve within a month to six weeks, we add a biologic medication. The purpose of these medications is to put the disease into remission. The drug of choice is an anti-TNF drug such as adalimumab (Humira), etanercept (Enbrel), or infliximab (Remicade).

If a patient does not respond to one of these medications within 2-3 months, we will switch to another anti-TNF medication.

If a patient does not respond optimally to two different anti-TNF drugs within 2-3 months, we move to a second-line biological treatment. There are two available. We try one first and if a patient doesn't respond, we move on to another.

One option is rituximab (Rituxan), a drug that targets B cells. Another option is abatacept (Orencia), a drug that targets T cells.

Occasionally, regular joint injections of corticosteroids are required.

While using all of these medications, we also recommend adequate rest and regular exercise once the patient feels better. Protecting your joints is just as important as proper nutrition. Proper nutrition and weight control are recommended. Antioxidant supplementation is valuable.

Pain relief with modalities such as acupuncture, physical therapy, massage, and low-level (cold) laser may also be helpful.

In many cases, anti-inflammatory herbs and homeopathic remedies also work well in conjunction with those mentioned above.

Adjunctive therapies such as hypnosis, guided visualization, meditation, and prayer are also often recommended.

Rheumatologists want to do more than control rheumatoid arthritis. We want to get it into complete remission. Fortunately, today it is possible.

Inspired by Nathan Wei