Treatment should be aimed at the prevention or control of joint damage, the prevention of the loss of function and to decrease pain. It is recognised that treatment should not be exclusively based on medication but should incorporate other elements as well.
These include education, exercise, sleep management and instructions on joint protection.
Education
People with Rheumatoid arthritis need to be informed of the implications of this disease and of the various treatment options. Patients should be made aware of the ways in which joint pain, fatigue stiffness can be reduced and should be encouraged to take an active role in managing their condition. Learning how joints function and the ways in which RA impairs function is an important part of understanding the disease. Better understanding and knowledge usually leads to more succesful outcomes.
It is also important that the patient's carers and immediate family are aware of these implications and any likely care needs that the patient may have.
Exercise
Both dynamic and aerobic exercise are useful for improving joint mobility, muscle strength, aerobic fitness and function. It is felt that exercise also improves psychological well-being. One of the most effective forms of exercise is swimming. For those who can't swim, the process of learning is a really effective way of minimising the damage. Structured exercises in water (aquaerobics) is described as a very valuable form of exercise by the Arthritis Research Campaign.
Analgesics
Analgesics are used to control pain, they are usually taken to supplement the pain relieving effects of other drugs. Paracetamol is the most frequently used analgesic but combination tablets such as cocodamol are also used.
Stronger analgesics such as tramadol are also available.
Constipation is the most common side effect when taking analgesics.
Non-steroidal Anti-inflamatory Drugs(NSAIDs)
NSAIDS are used to reduce pain and inflamation. Because they do not alter the course of RA nor prevent joint destruction,they are usually used in conjunction with disease modifying antirheumatic drugs or with biologic agents. The main problem with NSAIDS is that prolonged use can lead to gastro-intestinal problems such as ulcers and/or stomach bleeds.
The American College of Rheumatology(ARC) list the following as risk factors for the development of NSAID-associated gastroduodenal ulcers-
The ARC says that people with Rheumatoid Arthritis are nearly twice as likely as people with osteoarthritis to to have a serious complication arising from NSAID treatment.
Gastroprotective agents are often used to reduce the risk of stomach problems. These agents include high dose H2 blockers, proton-pump inhibitors and oral prostaglandin analogs.
Cox-2 Inhibitors
These are a type of NSAID that block an inflamation-promoting enzyme called COX-2(cyclo-oxygenase-2). Cox-2 inhibitors have fewer gastro-intestinal side effects and were recommended for use in people who may be at high risk of developing serious gastro-intestinal problems.
Recently Merck has withdrawn its Cox-2 Inhibitor (Vioxx) from the market after evidence showed an increased risk of heart problems. Merck is currently being sued by 30,000 people in the US who claim that their heart problems were caused by Vioxx. Current guidance in the UK suggests that this type of medication should only be given to those individuals who do not have a history of heart problems or those who are not considered to have an increased risk of heart disease.
This issue is very complex, if you have any concerns about your medication you should discuss these with your GP. The British Medical Journal has published an overview of the Vioxx controversy.
Medscape notes that "COX-2 inhibitors are not free of upper gastro-intestinal and renal side effects".
Disease Modifying Anti-Rheumatic Drugs (DMARDS)
As the name suggests, DMARDS work to reduce or prevent joint damage and to preserve joint function. Most guidance states that DMARDS should be prescribed within 12 weeks of diagnosis for those people who continue to experience joint pain, morning stiffness or fatigue whilst using NSAIDS. Listed below ar the most common types of DMARDS-
Biological Therapies
Biological therapies are those drugs which have been genetically engineered to target those agents which are responsible for inflammation. Both infliximab and etanercept represent a significant leap forward in the treatment of RA and reinforce the importance of early diagnosis and treatment.
Infliximab is an anti-TNF(tumour necrosis factor) drug given intravenously (via a drip). TNF is a substance which is thought to play a key role in the inflammation process. Infliximab attaches itself to TNFA and making it inactive. Infliximab, taken in conjunction with Methoxrate, is effective in stopping the inflammation and damage to the affected bones. Infliximab will not be prescribed if the RA is inactive, if "standard" DMARDs have not been tried first, for patients who are pregnant or breastfeeding or for patients who have an infection. Doctors are encouraged to exercise caution for when prescribing for patients who have had tuberculosis, multiple sclerosis, cancer, a serious heart condition or a history of repeated infections. The NICE guidance states that Infliximab should only be prescribed alongside Methoxrate. Infliximab usually takes effect within 2-12 weeks.
The ARC site says that infliximab may increase susceptibility to food-borne infections such as listeria and salmonella. In order to minimise this risk people are advised to avoid raw eggs and products made from raw eggs, unpasteurised milk, mould-ripened soft cheese, blue cheese, feta and goat's cheese, undercooked meat and poultry, all types of pate. Infliximab is given two weeks after the first infusion, a further infusion is given fours weeks after the second. It is then given once every eight weeks. Side-effects may include blocked nose, dizziness, headache, rashes, stomach pain or indigestion.
Etanercept is a anti-TNF drug which is injected at a dose of 25mg once or twice a week. The frequency of the injections will depend on patients' individual needs. The usual dose is 25mg given twice weekly. Etanercept works by preventing TNFa from attaching itself to joint tissue. Patients are encouraged to inject themselves although district nurses can carry out this task. Etanercept has the same side effects as infliximab and patients may also get an infection around the injection site. The same dietary precautions should be taken as etanercept also increases the risk of food-borne infections. Etanercept usually takes effect within 2-12 weeks.
Corticosteroids
Steroid injections are effective in reducing inflammation in the joint but prolonged use can lead to serious side effects such as osteoporosis, weight gain, hypertension, diabetes and cataracts. Steroids can be used in conjunction with DMARDs such as methoxrate until such time as the methoxrate takes effect (which is usually 12 weeks max). EULAR's recommendations for the management of early arthritis states that "Systemic glucocorticoids reduce pain and swelling and should be considered as a (mainly temporary) adjunct to the DMARD strategy. Intra-articular glucocorticoid injections should be considered for the relief of local symptoms of inflammation."
Injections are given directly into the inflamed joint. Steroids can also be given in tablet form.
Corticosteoids are normally given whilst the DMARD is taking effect.
