RHEUMOTOID ARTHRITIS Treatment Update
by Dr Vinaya Kunjir
Rheumatoid Arthritis (RA) is characterized by multiple painful swollen joints which progress to loss of function and deformities. RA also causes general constitutional symptoms of fever, loss of body weight, fatigue and often complication by anaemia, osteoporosis (thinning of bone) and premature heart diseases like heart attacks and strokes.
The cause of RA is unknown. RA arises in a genetically susceptible person upon exposure to a variety of environmental factors like occupation, lifestyle, personal habits, smoking and infections. The main target of inflammation is the Joint- the inner lining of the joint called synovium is the site of inflammation. Sooner or later, the inflammation spreads to the surrounding components of the joints such as cartilage, blood vessels, nerves, ligaments.
RA, if untreated can cause crippling deformities and lead to poor functioning of daily activities and unpaired quality of life.
GENERAL APPROACH TO THE PATIENT WITH RA
The treatment of RA has changed remarkably in the last 10 years. The key message from the current studies suggest 'early recognition' of the disease and 'early aggressive' treatment with DMARDS (Disease Modifying Anti Rheumatic Drugs) and if necessary with Biologic agents.
If treatment is started at an early stage of disease, it can prevent disease progression achieving a tight disease control.
How does a rheumatologist evaluate a patient of RA?
What are the investigations required?
Firstly, the rheumatologist makes a clinical examination of the joints to assess the inflammatory joint disease activity along with ESR, CRP status.
Measures the auto-antibody status – RF, Anti CCP/ACPA.
Plain X-rays or Ultrasound/MRI of joints if required to assess the damage in joints.
Assessment of risk factors such as measurement of blood pressure, plasma glucose, lipid profile, liver and kidney function status and cardiovascular status.
TREATMENT OF RA
1. Pain-relief / Pain killers
Pain is the worst disease in the universe. Pain in RA patients arises due to inflammation in the joints. Pain killers
drugs are classified into two groups – Analgesics which provide pain relief only.
Anti-inflammatory drugs which relieve pain and inflammation.
Common examples of analgesics are Paracetamol, tramadol, morphine and related compounds. Drugs belonging to morphine family are called opioids or narcotic analgesics. They are used in severe pain but have a tendency to cause addiction. Paracetamol – commonly known as Crocin / Pacimol / Calpol is a safe analgesic. It reduces headache and fever also.
The anti inflammatory analgesics are called as NSAIDS (non-steroidal anti-inflammatory drugs) Common examples of NSAIDS are Aspirin / salicylates, Ibuprofen, Meloxicam, Etoricoxib, etc. they are commonly used to relieve pain and swelling in RA. NSAIDS are usually safe but unregulated, long-term use can cause bad effects on the stomach and kidneys. Hence they should not be consumed without consulting the doctor. They should not be taken on empty stomach. Drink enough water throughout the day.
If NSAIDS have to be taken for long periods, anti-acidity drugs are usually prescribed with them.
Steroids (corticosteroids) are important drugs in the treatment of RA. They can relieve pain and swelling in joints very rapidly producing total symptomatic relief. But they also have toxic side effects on the body. Unregulated and long term use of steroids can cause weight gain, hypertension, diabetes, cataracts, skin infection, osteoporosis and fragility fractures. Hence they should be used with caution. Some doctors use them as painkillers which is wrong.
Prednisolone (Wysolone, Omnacortil), MethylPrednisolone (Medrol), Deflazacort are the most commonly used steroids.
Sometimes steroids can be injected intra-acticularly into joints to reduce pain swelling in the joints.
3. Disease Modifying Agents in Rheumatic Disease (DMARDs)
DMARDs are the backbone of the RA treatment. They are the first step in the treatment of RA and should be started in all patients after diagnosis. The synthetic DMARDs most commonly used are Methotrexate, Sulfasalazine, Leflunomide, Hydroxychloroquine.
Methotrexate – it is the anchor drug in the treatment of RA. It is effective over long period of time and has a good safety profile. It can be given usually as tablets or parenterally as injections. Its action starts after 6-8 weeks on administration side effects include nausea, vomiting, liver toxicity, anaemia, decreased WBC and platelet count in blood, skin rashes, susceptibility to injections.
RA patients on Methotrexate should be monitored every 6-8 weeks in order to assess the disease activity and also to watch for the side-effects.
Leflunomide – This is another DMARD used in the treatment of RA. It is given as oral tablets – 10mg or 20mg tablets. Side effects include raised liver enzymes, skin rashes, hair fall, nausea & vomiting. It is not safe to use Leflunomide in pregnancy due to its toxic effects on the fetus. Leflunomide is contra-indicated in lactating women and in young women who are keen for pregnancy.
Sulfasalazine – This DMARD can be used alone or in combination with Methotrexate for treatment of RA. It is relatively safe in pregnancy or in breast feeding women. Side effects are anaemia, decreased WBC/ platelet count, skin rashes.
Hydroxychloroquine (HCQS) – This anti-malarial agent is a slow acting DMARD and usually used in combination with other DMARDs. Its most feared side effect is retinopathy. Hence a baseline and annual eye checkup is necessary for all RA patients on HCQS.
4. BIOLOGICAL DISEASE MODIFYING AGENTS IN RHEUMATIC DISEASES (BIOLOGICAL DMARDs).
The pattern of RA changes from person to person. Some patients may have a mild illness but some may suffer from a severe RA which can program to crippling deformities in a short duration. The first line of treatment of RA is the synthetic conventional DMARDs. If RA is severe & progressive and the effect of conventional DMARDs is less than optimal, then Biological Drugs should be considered.
Biological Drugs are a new class of drugs which are capable of hitting the precise disease targets involved in the inflammatory process of RA. The biologics can stop the initial disease process events and control the inflammatory process quickly preventing the body damage and deformities. They can also prevent & heal the bone damage and diseases like osteoporosis. There are several biologic drugs available in the US and Europe and now in India also. Some of them are Infliximab (Remicade-trade name), Etanercept (Enbrel), Rituximab (Mabthera), Tocilizumab (Actemra), Abatacept (Orencia). Recently several companies in India are engaged in developing BIOSIMILAR DMARDS. These Biosimilar drugs are considered equivalent to original Biologic drugs in efficacy and safety. They also cost less than the original Biologic drugs. Biosimilars of Infliximab, Etanercept, Adalimumab and Rituximab are now available in India.
Though Biologics are very successful in the treatment of RA, they have to be used very carefully. While controlling RA, they suppress very critical components of the immune system which makes the patients prone to infections. One of the major concerns with biologics is an increased risk of tuberculosis. Hence before beginning biologic treatment, the patient should be checked for past, hidden or present tuberculosis.
Our experience with Biologic DMARDs is less than a decade of use. Some studies suggest that biologics cannot be given to patients with heart diseases or neurological disorders.
In India, the most important problem with biologics is their cost. They are expensive drugs and hence cannot be given to all patients of RA. Hence in the current Indian settings, only affording patients with severe, progressive disease can be given Biologics. Only rheumatologists are authorised to prescribe and use Biologic Drugs.
The ultimate goal of treatment of RA is to keep the disease under complete control to minimize joint damage and crippling deformities. Hence aggressive management with the use of conventional DMARDs and early use of Biologics is indicated.