Key principles
A The rheumatologist should be the primary expert in the treatment of patients with rheumatoid arthritis.
B Patients with rheumatoid arthritis and rheumatologists should consult together for the best treatment.
C The medical and human costs of rheumatoid arthritis are expensive, and the rheumatologist should take these into account.
15 recommendations for rheumatoid arthritis treatment
1. Once rheumatoid arthritis has been diagnosed, nonbiologic disease-modifying drugs should be started as soon as possible.
2. For each patient, the goal of treatment should be to achieve remission or hypermobility as much as possible. As long as the goal is not achieved, the treatment regimen should be continuously adjusted (every 1-3 months) and strictly monitored.
3. Methotrexate should be used as one of the first-line disease-modifying drugs for patients with active rheumatoid arthritis.
When methotrexate is contraindicated (or not tolerated), subsequent disease-modifying agents include: leflunomide, salazosulfapyridine, or injectable gold formulations.
5. Patients who have not used a condition modifying agent, with or without the addition of hormones, may be treated with a single abiotic condition modifying agent rather than a combination of multiple abiotic condition modifying agents.
6. The addition of small to moderate amounts of hormones to a single or multiple condition-improving drugs can be beneficial in the short term, but should be tapered as soon as clinically possible.
7. If the treatment goal is not achieved with the earliest disease-modifying drug and there are factors of poor prognosis, biological disease-modifying drugs should be added. In the absence of poor prognostic factors, consideration should be given to switching to other non-biologic disease-modifying drugs.
8. Biologic disease-modifying agents should be initiated in patients who have not responded well to methotrexate and/or other non-biologic disease-modifying agents (combined or uncombined with hormones). The current recommendation is to initiate treatment with anti-tumor necrosis factor inhibitors (Iceptab, classical, adalimumab, and certolizumab) in combination with methotrexate.
9. For patients with rheumatoid arthritis who have failed the first antitumor necrosis factor inhibitor, other antitumor necrosis factor inhibitors, abciximab, melphalan, or tocilizumab should be used.
10. Patients with contraindications to biologic agents or previously mentioned nonbiologic disease-modifying agents, or refractory severe rheumatoid arthritis, may wish to consider the following nonbiologic disease-modifying agents alone or in combination with the disease-modifying agents mentioned above: azathioprine, cyclosporine A (or cyclophosphamide in individual cases).
11. Although patients with poor prognostic factors should be treated more aggressively, each patient should be treated aggressively with medication.
12. For patients in sustained remission, gradual reduction of hormones may be followed by gradual reduction of biologic disease-modifying agents, especially when combined with non-biologic disease-modifying agents.
13. For patients in sustained long-term remission, the dose of non-biologic condition modifying drugs may be cautiously reduced, a decision to be made jointly by the physician and the patient.
14. Patients who have never used a disease-modifying drug but have a poor prognosis may be considered for treatment with MTX in combination with biologic agents.
15. When adjusting therapy, the progression of structural joint damage, comorbidities and safety issues should be considered in addition to disease activity factors.