These goals include:

• Education of the patient

• Relief of pain

• Preservation and restoration of function

• Modification of disease progression and damage

With the acquired understanding of the early onset of damage and the ultimate impact on the debility and disability of the rheumatoid arthritis patient, the algorithms of treatment have changed focus to a more aggressive and early approach. The concept of treating to a target of remission or low disease activity state is now widely accepted.

NONPHARMACOLOGIC TREATMENTS

The physician will need to enter into a treatment partnership with the rheumatoid arthritis patient. The education of the patient as to his or her disease features, course, prognoses, and medication adverse effects is the key to a successful treatment program.

Exercise with stretching and strengthening of the involved joints is beneficial in the majority of cases, and patients should be encouraged to stay active (see Plates 5-10 and 5-11). Patients may benefit from a consultation with an occupational and/or physical therapist to help guide and outline an exercise plan. Rest and/or splinting of an acutely inflamed joint may be necessary in some cases. Bed rest and hospitalization is rarely needed in the present era.

Rheumatoid arthritis patients should be encouraged to eat a healthy and balanced diet. Overweight patients should be encouraged to lose weight because excess weight placed on inflamed joints may hasten the damage. There are very little data to support a specific diet in rheumatoid arthritis. An exception may be the increase in dietary or supplemental fish oils, which may provide an anti-inflammatory effect.

Many patients are curious about alternative and complementary pathways of treatments. Unfortunately, there are little data to support the efficacy or ensure the safety of these therapies.

PREVENTATIVE TREATMENTS

The rheumatoid arthritis patient should be encouraged to discontinue tobacco use because there are good data to support the poor prognostic implications of smoking.

Rheumatoid arthritis and other inflammatory and autoimmune diseases appear to be independent risk factors for cardiovascular disease. In addition to cessation of smoking, the individual patient should be assessed for other cardiovascular risk factors, and these should be modified as deemed indicated.

Decreased bone mineral density is common in rheumatoid arthritis patients. Other risk factors including postmenopausal state and corticosteroid use may contribute. Patients should be assessed by bone densitometry testing, and then treatment directed toward bone health should be rendered as indicated.

As a general rule, it is recommended that patients have updated all of their age-appropriate malignancy screens and vaccinations. Some vaccinations may be less effective or contraindicated while certain immunosuppressive medications are being used.

PHARMACOLOGIC TREATMENTS

Pharmacologic treatment for rheumatoid arthritis is divided into five categories:

• Analgesics

• Nonsteroidal anti-inflammatory drugs (NSAIDs)

• Corticosteroids

• Nonbiologic disease-modifying antirheumatic drugs (DMARDs)

• Biologic DMARDs

As outlined previously, aggressive and early treatment regimens are now the standard of care for rheumatoid arthritis, and most patients will warrant being started on one or more DMARDs at their initial diagnosis. All other medications, including analgesics, NSAIDs, and corticosteroids, are considered adjunctive or bridge therapies. The treatment options will be initiated and further adjusted based on the patient’s disease duration, prognosis, severity and activity. Both the ACR (in 2008) and EULAR (in 2010) have put forth recommendations for the pharmacologic management of patients with rheumatoid arthritis. The goal of such treatment is to have the patient reach a state of low disease activity or preferably remission.