Pain / NSAID Med
Major Sx includes symmetrical plyarthritis with joint swelling &
tenderness & morning stiffness lasting for > 1 hour. Subcutaneous
nodules, + rheumatoid factor, & x-ray evident erosions
or juxta-articular osteoporosis are further characteristics of RA.
ACR Criteria for Rheumatoid Arthritis (*symptoms must
be present for > 6 weeks)
Morning Stiffness > 1 hour*
Arthritis of three or more joints*
Arthritis of hand joints*
Serum rheumatoid factor >1:160
Radiographic changes consistent with RA
If more than 4 are positive then patient has RA.
The goals of Rx are to alleviate pain, control inflmmation, preserve the
joint & daily activity function , & to prevent joint destruciton.
Disease-Modifying Anti-Rheumatic Drugs (DMARD)
Toxic effects requiring follow-up
200-600 mg/day in 1 or 2 doses with meal
||yearly eye exam
7.5 - 25 mg PO. subc, IM/wk
|myelosuppresion, hepatic fibrosis, cirrhosis, pulm. infiltrates or fibrosis.
Folate 1 mg supplement
50-150 mg/d in 1-3 doses with meal
|myelosuppresion, hepatotoxicity, lymphoproliferative disorders
||CBC, LFT q1-2wks
2-15 mg/d PO; 20-60 mg/d for extra-articular vasculitis.
|hypertension, hyperglycemia, osteoporosis
||BP, glucose, bone density scan
2.5 -5 mg/kg/d in 1 or 2 doses
|renal insufficiency, anemia, hypertensio, hirsutism
||Creat, lytes,CBC, LFT
125-250 mg/d, max<1500mg/d
10 or 25 mg subc 2x/wk, x 6 months
March 16, 1999;130:478 - Larry Moreland)
|injection site reaction, flu-like Sx
100 mg/d x 3 d, then 10-200 mg/d
|thrombocytopenia, hepatotoxicity, diarrhea
||CBC, LFT q4-8wks
(Humira) 40 mg subc q other week
TNF-alpha antagonist 3 mg/kg IV q8wks
|flu-like Sx, autoantibody development
10 mg first, then 25 mg next wk, then 25-50 mg/wk;
Gold PO Auranofin (ridaural) cap
3-9 mg/d in 1-3 doses
2-3g/d in 2-4 doses
||CBC, LFT, Creat q2-4wks
200 mg/d in 2 doses on empty stomach
|photosensitivity, skin discoloration, GI upset, dizziness, drug-induced
Scenarios Illustrating the Practical Application
of Therapeutic Strategies for RA
Newly diagnosed RA in a young patient with presence of RF & mild disease
(few joints involved & ESR <30)
Rx: Hydroxychloroquine 400 mg/d with or without NSAID med, and prednisone
3-5 mg/d over a 1-3 months period; sulfasalazine, upto 3 g/d in 2 divided
doses, is an acceptable alternative.
New onset RA with pronounced Sx including fatigue, low-grade fever, weight
loss, & polyarticular disease.
Rx: Methotrexate, with NSAID med, and prednisone 5-15 mg/d; taper prednisone
over a 3-4 months period if possible. If adequate control cannot be achieved
after the initial 6-8 wks of Rx, consider adding hydroxychloroquine,
sulfasalazine, or both to this regimen; a frequent cause of "Methotrexate
failure" is an inadequate dose of methotrexate (providing that the patient
is able to tolerate the higher doses)
Patient with established mild disease.
Rx: hydroxychloroquine 400 mg/d, with or without an NSAID, and prednisone
3-5 mg/d over 1-3 months period; sulfasalazine, up to 3 g/d in 2 divided
doses is an acceptable alternative.
Established RA in whom optimal dose of methotrexate is partially
NSAID, if they add measurably to Sx control; prednisone 5-15 mg/d
*Initiate combination: Rx: may add hydroxychloroquine, sulfasalazine,
*If combination Rx with hydroxychloroquine, sulfasalazine, or both is
Rx: Discontinue hydroxychloroquine & sulfasalazine; add leflunomide,
azathioprine, cyclosporine, or possibly gold.
*If combination Rx with methotrexate & cyclosporine, leflunomide,
or azathioprine is poorly tolerated or ineffective:
Rx: Continue methotrexate but discontinue the combination drug &
add etanercept or infliximab. TNF-alpha antagonists should be avoided
in patients with chronic infections, draining nodules, or history of TB or
TB exposure; discontinue these agents 7-10 days before & after major
Established RA in whom methotrexate is effective, not tolerated, or
Rx: For mild disease: leflunomide, sulfasalazine, & azathioprine.
For severe disease: cyclosporin & combinations of DMARDs such as
sulfasalazine, hydroxychloroquine, & others, or etanercept or infliximab;
gold may be considered, particularly in combination with any of these therapies,
although it is rarely tolerated or useful.
Patients with established seronegative RA.
Rx: Of importance, decision about use & aggressiveness of DMARD Rx should
not be based solely on the presence or absence of the rheumatoid factor (RF).
Rx must be tailored to the disease manifestations in the individual
Mayo Clin Proc. Jan. 2000;75:69 - Eric Matteson "Review of
Current Rx for RA"
New treatments for rheumatoid arthritis -Kenneth H. Fye
106 / NO 4 / OCTOBER 1, 1999 / POSTGRADUATE MEDICINE
Arthritis (KP Intranet)