Treatments differ for rheumatoid arthritis

Treatments differ for rheumatoid arthritis

Q: My mother has rheumatoid arthritis, which developed about a year ago. Could you tell me what treatments are used now and who to see about it?

A: The current treatment of rheumatoid arthritis is not new news at this point. During the past 15 years, the standard of care shifted from what we all were used to. Previously, a doctor would prescribe drugs like aspirin, ibuprofen, naproxen and other NSAIDS (non-steroidal anti-inflammatory drugs). If that didn't work well enough, the next step would be gold therapy, or prednisone. Finally, if the disease progressed, the doctor would turn to low doses of drugs used for cancer chemotherapy. In low doses, physicians call these "disease-modifying agents."

Rheumatoid arthritis and several other "autoimmune" diseases come from the immune system mistakenly attacking the person rather than foreign invaders. Therefore, the joints are the prime target in rheumatoid arthritis, causing deformity and loss of function. In lupus (SLE), many types of connective tissue and organs are targeted, and the joint disease doesn't cause deformity.

For many years, doctors hesitated to use the cancer treatment drugs, even though they knew that these drugs knocked the immune system down. The fear of the possible side effects kept these drugs in reserve. Then a change of heart occurred.

Years of experience with low doses of these cancer drugs had proven that low dose treatments had very little risk and did little or no serious harm compared to the terrible joint destruction that was occurring. Gradually, the thought grew that intervention should be done at the front end of the disease, rather than the later period. Once the disease destroys the joints, it's too late. Joint erosion is already visible by the fourth month of active disease on MRI.

However, not all people who present with inflammatory arthritis that might be rheumatoid arthritis have it. About half of patients have an undifferentiated illness in which half of those (or 25 percent of the total group) will go away spontaneously. In the remaining 20 percent or so who do actually have rheumatoid arthritis, approximately half will recover spontaneously as well.

So, how do doctors decide who should be treated early and aggressively? There are criteria that apply, and if a person fulfills enough of these criteria, then treatment makes sense.

The criteria are as follows:

Erosions seen on X-ray at the first doctor's visit

Joint inflammation lasting longer than six weeks

A blood test called the anti-CCP, whose result is over 92

Antibodies against rheumatoid factor

Pain felt when the doctor presses on the first knuckle in both hands

Morning stiffness lasting over an hour and arthritis affecting more than two joint groups