9Drug management of early rheumatoid arthritis – 2008☆
Section snippets
A concept of early RA
The term ‘rheumatoid arthritis’ is used to describe a syndrome that may result in a destructive symmetrical polyarthritis and is often associated with the presence of rheumatoid factor [31]. Identification of RA in the early stages is both important and difficult. Criteria for RA have been developed since 1907 [32]. However, even the current set of criteria, the American Rheumatism Association (now the American College of Rheumatology, ACR) 1987 revised criteria [33], do not differentiate
Early versus delayed drug treatments in randomized controlled trials of early RA
The benefits of early versus delayed treatment have been documented in studies of intramuscular (IM) gold [41], auranofin [42], sulphasalazine (SSZ) [43], [44], and hydroxychloroquine (HCQ) [45]. Disease duration at the time of DMARD initiation was the primary predictor of the response to DMARD treatment in a meta-analysis [46]. One study concluded that very early treatment with MTX may postpone the development of RA [47].
The Finnish RA Combination Therapy Trial, termed the FIN-RACo study,
Historical perspective concerning the treatment of early RA
Benefits of early versus delayed drug treatments in RA were first recorded in an observational study by Luukkainen et al [54] which showed that patients treated with IM gold early in the course of RA had lower radiographic progression over 5 years than those treated with gold at later stages. These results have been confirmed in further observational studies of other DMARDs [55], [56], [57], *[58].
Several early RA cohorts have been established in Finland since the 1970s. Longitudinal
General principles of drug therapy for RA
The contemporary approach to patients with early arthritis is based on identification of patients with early RA, early use of available therapies in suspected cases to control inflammation as completely as possible, tight control according to quantitative monitoring in order to prevent long-term damage [73], and using methotrexate as the anchor drug *[73], [74].
Conclusion
Treatments for early RA should aim for remission as soon as possible to avoid severe side-effects of RA. Patients with early RA should be seen frequently and monitored tightly. MTX is the anchor drug, although therapies should be tailored individually for each patient.
The authors of this chapter represent a typical patient with early RA with respect to sex (female) and age (mean 50.1; SD 2.7). If we developed early active RA, we would begin MTX up to 25 mg and low-dose prednisolone (5 mg) (with
Acknowledgments
Theodore Pincus for helpful comments.
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Modified and updated from: 1. Sokka T, Envalds M, Pincus T. Treatment of rheumatoid arthritis: a global perspective on the use of antirheumatic drugs. Mod Rheumatol. 2008 Apr 25. 2. Sokka T, Hannonen P, Möttönen T. Conventional disease-modifying antirheumatic drugs in early arthritis. Rheum Dis Clin North Am. 2005 Nov;31(4):729-44. Review.