RA usually requires lifelong treatment, including various medications, physical therapy, education, and possibly surgery aimed at relieving the signs and symptoms of the disease.
MEDICATIONS
For the past 10 years, studies have shown that early, aggressive treatment for RA can delay the onset of joint destruction. In addition to rest, strengthening exercises, and anti-inflammatory agents, the current standard of care is to initiate aggressive therapy with disease-modifying anti-rheumatic drugs (DMARDs) once the diagnosis is confirmed.
Anti-inflammatory agents used to treat RA traditionally included aspirin and non-steroidal anti-inflammatory drugs (NSAIDS), such as ibuprofen (Motrin, Advil), fenoprofen, indomethacin, naproxen (Naprosyn), and others.
These are widely used medications that are effective in relieving pain and inflammation associated with RA. However, side effects associated with frequent use of many of these medications include life-threatening gastrointestinal bleeding.
Similar drugs, called Cox-2 inhibitors, are now a mainstay of anti-inflammatory therapy because the risk of gastrointestinal bleeding is significantly reduced with these drugs. Currently, there are two available -- rofecoxib (Vioxx) and celecoxib (Celebrex).
As mentioned, DMARDs alter the course of the disease. Included in this group are gold compounds, which can be injectible (Myochrysine and Solganal) or oral (auranofin/Ridaura). Methotrexate (Rheumatrex) is the most commonly used DMARD for rheumatoid arthritis with good proven effectiveness.
Antimalarial medications, such as Hydroxychloroquine (Plaquenil), as well as Sulfasalazine (Azulfidine), are also beneficial, usually in conjunction with Methotrexate.
The benefits from these medications may take weeks or months to be apparent. Because they are associated with toxic side effects, frequent monitoring of blood tests while on these medications is imperative.
In the last few years, new and exciting medications have been introduced. A promising medication that is fast becoming a first-line agent for the aggressive treatment of RA is called etanercept (Enbrel). Enbrel acts by inhibiting an inflammatory protein, called tumor necrosis factor (TNF).
Other new medications include infliximab (Remicade) that also blocks TNF and leflunomide (Arava), which blocks the growth of new cells. Anakinra is an even newer therapy that blocks the action of another inflammatory protein, interleukin-1. Anakinra and Etanercept are injectable medications, whereas Infliximab is given intravenously every 2 months.
Drugs that suppress the immune system, like azathioprine (Imuran) and cyclophosphamide (Cytoxan), may be used in people who have failed other therapies. These medications, which are associated with toxic side effects, are reserved for severe cases of RA.
Corticosteroids have been used to reduce inflammation in RA for greater than 40 years. However, because of potential long-term side effects, corticosteroid use is limited to short courses and low doses where possible.
Side effects may include bruising, psychosis, thinning of the bones (osteoporosis), cataracts, weight gain, susceptibility to infections, diabetes, and high blood pressure. A number of medications can be administered in conjunction with steroids to minimize resultant osteoporosis.
Consult a health care provider before long-term use of any medication, including over-the-counter medications.
SURGERY
Occasionally, surgery is indicated for severely affected joints. The most successful surgeries are those on the knees and hips. Usually, the first surgical treatment is removal of the synovium (synovectomy).
A later alternative is total joint replacement with a joint prosthesis. Surgeries can be expected to relieve joint pain, correct deformities, and modestly improve joint function. In extreme cases, total knee or hip replacement can mean the difference between being totally dependent on others and having an independent life at home.
LIFESTYLE CHANGES
Range of motion exercises and individualized exercise programs prescribed by a physical therapist can delay the loss of joint function.
Joint protection techniques, heat and cold treatments, and splints or orthotic devices to support and align joints may be very helpful.
Frequent rest periods between activities, as well as 8 to 10 hours of sleep per night are recommended.
OTHER THERAPY
Prosorba column is a device approved by the FDA in 1999 for treatment of moderate to severe RA in adult patients with long-standing disease (who have not responded to DMARD's).
It works by removing inflammatory antibodies from the blood by a process called apheresis. The blood is removed through a small catheter and then passed through a column (the size of a coffee mug) that is coated with a substance called protein A.
Protein A binds with the antibodies and removes them from the blood. The blood is then given back. The procedure takes 2-3 hours, and must be done once a week for 12 weeks.
Studies have reported that one third to one half of the people who receive this treatment may slow down, or even stop the RA from worsening. Reported side effects include anemia, fatique, fever, low blood pressure, and nausea. Some people have developed an infection from the catheter. Often there is a flare-up of joint pain for several days after the treatment.
Sometimes therapists will use special machines to apply deep heat or electrical stimulation to reduce pain and improve joint mobility.
Occupational therapists can construct splints for your hand and wrist, and teach you how to best protect and use your joints when they are affected by arthritis. They also show people how to better cope with day-to-day tasks at work and at home, despite limitations caused by RA.
MONITORING
Depending on the medications being taken, regular blood or urine tests should be done to monitor both progress and negative side effects.
