RHEUMATOID ARTHRITIS-MANAGEMENT (NON BIOLOGIC DMARDs)

SUMMARY

1. Early treatment with a DMARD may alter the course of the disease: initiate within 3 mths of symptoms, add additional DMARDs or biologic agents as required.

2. NSAIDs decrease inflammation and joint swelling but do not alter the course of the disease.

3. The anti-inflammatory effects of COX-2 inhibitors are comparable to NSAIDs, with reduced GI effects, less risk of bleeding & no effect on platelets, but increase risk of adverse cardiac events.

4. DMARDS (methotrexate, leflunomide, hydroxychloroquine), have a slow onset of action (several months), so concurrent NSAIDs or low-dose glucocorticoids are required initially.

5. MTX is an anti-folate agent with anti-inflammatory properties: initial DMARD for moderate-to-severe RA and the main DMARD when combination therapy is used in those with poor prognostic features.

6. Contraindications to MTX: pre-existing liver disease (HBV, HCV, heavy alcohol use), severe renal disease, pregnancy.

7. SE of MTX: alopecia, GI upset, bone marrow suppression, hepatotoxicity, pneumonitis, nephrotoxicity.

Reference(s)

Wilkinson, I., Furmedge, D. and Sinharay, R. (2017). Oxford handbook of clinical medicine. Oxford: Oxford University Press. Get it on Amazon.
Feather, A., Randall, D. and Waterhouse, M. (2020). Kumar And Clark’s Clinical Medicine. 10th ed. S.L.: Elsevier Health Sciences. Get it on Amazon.
Hannaman, R. A., Bullock, L., Hatchell, C. A., & Yoffe, M. (2016). Internal medicine review core curriculum, 2017-2018. CO Springs, CO: MedStudy.
Therapeutic Guidelines. Melbourne: Therapeutic Guidelines Limited. https://www.tg.org.au [Accessed 2021].