Diagnosing rheumatoid arthritis (RA) early in the disease process is ideal, because treatments are more likely to be effective and less damage will occur. Guidelines from the American College of Rheumatology (ACR) and the European League Against Rheumatism (EULAR) state that using newer biologic medications, in addition to more aggressive dosing of traditional medications, is the optimal way to achieve results.1,2 This combination tends to control disease activity and joint inflammation, decrease erosions and damage to joints, improve the quality of life for people with RA and decrease such co-morbidities as cardiovascular disease that can be associated with sustained inflammation.
Nonetheless, treatment decisions can be complex because many factors come into play. Rheumatologists should make treatment decisions along with their patients, because patients are more likely to comply with treatment if they are involved in the decision-making process.
“Discussions should include the risks of RA, the risks of therapeutic choices and the anticipated benefits and side effects,” says Susan M. Goodman, MD, rheumatologist and associate director of the Inflammatory Arthritis Center of Excellence at the Hospital for Special Surgery (HSS) in New York.
When determining the best treatment protocol, Vivian Bykerk, MD, rheumatologist and director of the Inflammatory Arthritis Center of Excellence at HSS, considers disease characteristics to estimate a person’s prognosis. Factors include how long the patient has had the disease, how widespread the signs and symptoms are, laboratory results, imaging results and whether damage has already occurred. Poor prognostic signs in patients with RA include extensive joint involvement, positive rheumatoid factor and cyclic citrullinated peptide antibodies, increased inflammatory markers and joint erosions at initial diagnosis.
Dr. Bykerk also wants to know whether the patient has already taken medication for their symptoms, as well as their treatment goals and insurance coverage. “I’ll explore the patient’s values, their concerns about the disease and what they have read about in terms of its treatment and risk tolerance,” Dr. Bykerk continues. “Finally, we develop clear goals for treatment.”
Starting & Evaluating Treatment
The ACR and EULAR guidelines call for prescribing a disease-modifying anti-rheumatic drug (DMARD) upon diagnosing a patient with RA. In most patients with moderate to severe, active RA, methotrexate is the initial treatment of choice. In fact, most insurance companies require a patient to have had an inadequate response to methotrexate before starting a biologic, says Monica Piecyk, MD, rheumatologist at New England Baptist Hospital in Boston.